RN UM Coordinator - Paramount - Remote - Per Diem

Perform effective preadmission, initial, concurrent, and post-discharge medical management for outpatient/ambulatory, inpatient, LTAC, SNF, and home health authorizations. Identify members for potential case management and referral needs. Reviews clinical submitted by providers to identify any transition of care needs and assists with this process.Authorize and facilitate ambulatory services, acute care/post-acute care, and home health care as well as out-of-plan services, considering the members individual needs, and utilizing panel providers whenever possible for cost-effectiveness. Precertify/certify and concurrently review requests for care utilizing InterQual level of care criteria to ensure appropriate medical care in the most cost-effective setting. Utilize nursing education and experience to evaluate the appropriateness of requests relative to the members diagnosis(es)/condition.Assess all members receiving care for post-discharge or Case Management needs. Refer members directly to Case, Behavioral, or Disease Management (depending on the product) to ensure that the member receives appropriate medical care and services, in the most cost-effective setting, to maintain or improve health status when possible, and prevent avoidable readmissions. As appropriate, collaborate with hospital discharge planning staff to identify an appropriate post-discharge plan of care for hospitalized members. Confer with physician offices, ancillary providers, Plan Case Managers, and Medical Directors on pertinent case questions or situations when evaluation or decision is beyond the scope of the Coordinator. Send post-discharge letters, as appropriate, to follow up and further assess the members situation, functioning, and compliance with the follow-up plan. Document ambulatory and inpatient medical management, in the appropriate system applications, according to current Company and Department policies and procedures. Complete all related reporting documentation according to established timeframes. Comply with all Federal, State, accreditation, professional and corporate regulations, standards, and policies pertaining to privacy and confidentiality. Identify potential high-dollar cases and collaborate with the Finance Department on case-specific expected risks; Report any quality issues identified during clinical documentation review. Identify and report any concerns for fraud, waste, and abuse to the internal investigation unit.Enforce prior authorization contract language and regulatory compliance requirements for network providers. Enforce regulatory compliance requirements for out-of-network providers.Initiate single care agreement requests with out-of-network providers and initiate sanction/exclusion investigation review for out-of-network provider requests.Assist in the investigation of provider complaints and ODM complaints when warranted. Perform other duties as directed.REQUIRED QUALIFICATIONSEducation: Associates Degree in NursingSkills: Excellent interpersonal, communication (oral and written), and organizational skills required. Ability to plan, coordinate and organize multiple priorities. Basic PC skills: Windows, word processing, emailYears of Experience: Minimum 2-3 years recent clinical or utilization review/medical management experienceLicense: Current Ohio and Michigan nursing license (Michigan registered nurses license must be obtained within three months of employment or transfer into position) PREFERRED QUALIFICATIONSEducation: Bachelors Degree in NursingSkills: Knowledge of InterQual criteria (or similar); knowledge of ICD, CPT, and DRG coding preferred.Years of Experience: 3-5 years of clinical experience, with a utilization management backgroundLicense: Ohio, Michigan, IndianaCertification: WORKING CONDITIONSPersonal Protective Equipment: Physical Demands: Ability to move between company workstations and departmentsProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio.For more information, please visitwww.promedica.org/about-promedicaQualified applicants will receive consideration for employmentwithout regard to race, color, national origin, ancestry, religion,sex/gender (including pregnancy),sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contactemployment@promedica.orgEqual Opportunity Employer/Drug-Free Workplaceby Jobble

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