Utilization Management RN in ‎Philadelphia, PA at Pyramid Consulting, Inc

Date Posted: 8/6/2019

Job Snapshot

Job Description

Immediate need for a talented Utilization Management RN with experience in the Insurance Industry.This is a 06+ Months contract opportunity with long-term potential and is located in ‎Philadelphia, PA. Please review the job description below.
Job ID: 18-53692
Key Requirements and Technology Experience:
  • Using the medical software criteria, establish the need for inpatient, continued stay and length of stay.
  • Directs the delivery of care to the most appropriate setting, while maintaining quality.
  • Contacts attending physicians regarding treatment plans/plan of care and clarifies medical need for inpatient stay or continued inpatient care
  • Identifies inpatient admissions no longer meeting criteria and refers care to plan Medical Directors for evaluation.
  • Presents cases to Medical Directors that do not meet established criteria and provides pertinent information regarding member's medical condition and the potential home care needs.
  • Performs early identification of hospitalized members to evaluate discharge planning needs.
  • Collaborates with hospital case management staff, physician and family to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.
  • Identifies and refers cases for case management and disease management.
  • Identifies quality of care issues including delays in care. Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination - when indicated.
  • Maintains the integrity of the system information by timely, accurate data entry. Utilization decisions are in compliance with state, federal and accreditation regulations.
  • Works to build relations with all providers and provides exceptional customer service.
  • Reports potential utilization issues or trends to designated - and recommendations for improvement.
  • Participates in the process of educating providers on managed care.
  • Performs additional related duties as assigned.
  • Registered Nurse/BS preferred. Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting. Prior discharge planning and/or utilization management experience is required.
  • Exceptional communication skills on all levels.
  • Proficiency in using computerized applications.
  • Problem solving ability.
  • Organized, demonstrated excellent team management skills.
Our client is a leading Insurance Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.