Remote Utilization Management RN

Salary 80000-90000 per year
Full Time

Imagine360 is currently seeking a Utilization Management RN to join our team. This RN is responsible to provide utilization review/notifications and education for individuals under the group health plans administered by GPA by utilizing nursing education, clinical, and professional experience. The Registered Nurse will practice within the scope of practice while performing assessments, coordination, planning, monitoring and evaluation.

Position Location: 100% Remote

Responsibilities include but are not limited to:

• Perform all tasks in accordance with Department of Labor, HIPAA, ERISA and Medical Management Policy and Procedure
• Complete HIPAA and URAC training annually
• Identify, collect, process and manage data to complete reviews for Medical Necessity per Imagine360 approved clinical guidelines.
• Accurate utilization and documentation in appropriate software including time slips in CaseTrakker to complete and document the review process .
• Provide oversight to non-clinical staff members regarding interpretation of clinical data.
• Consult with Physician Advisor or peer reviewer as needed per policy.
• Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Medical Managment Services.
• Communicates professionally and effectively as needed with members, physicians, other healthcare professionals, peers and manager of UM to complete the utilization process.
• Utilize clinical knowledge, expertise and approved educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment.
• Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite.
• Participate in the Quality Management program of the organization by completing the Quality Assurance review process and other procedures per policy and procedure.
• Evaluating clinical data.
• Assessment and evaluation of the acquired clinical data to assess for appropriateness of treatment plan based upon clinical guidelines.
• Coordination of treatment plans, interventions and outcomes measurement
• Rationale for the effects of medication and treatments.
• Provide patient education and educational resources.
  • Accurately report:
    • Administration of medication and treatments
    • Client response
    • Contact with other health care team member
    • Respect the client’s right to privacy by protecting confidential information
    • Promote and participate in education and counseling to a participant based on health needs
    • Clarify any treatment that is believed to be inaccurate, non-effacious, or contraindicated by consulting with appropriate practitioner

Required Experience / Education:

Nursing Degree from an accredited college or university

Active and unrestricted Registered Nurse License in eNLC compact state.

Minimum of one year experience in utilization review services or transferable nursing skills. Prefer knowledge of CPT and ICD coding.

Licenses or Certifications: Must maintain active Registered Nurse license and CEU’s as required by the State Board of Nursing. Must be willing to obtain and maintain additional license as required to perform the job functions of the organization. Must possess a valid driver license, proof of automobile insurance and a clean department of motor vehicles record if driving is required for company business.

What can Imagine360 offer you?

• Multiple Health Plan Options, including a 100% Employer Paid Benefit Options
• 100% Company paid employee premiums for Dental, Vision, STA, & LTD, plus Life Insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company’s diversity and inclusion initiatives

Want to see our latest job opportunities? Follow us on LinkedIn

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we’ve helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today’s one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV’s submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**