Full-Time Utilization Management Nurse I

• As a Utilization Management (UM) Nurse, you will provide UM services, transition of care and support to members and health care providers.
• Utilize clinical knowledge and expertise to interpret and appropriately apply medical policy, medical necessity criteria (InterQual), and benefit information to provide consultation and responses to UM requests.
• Proactively assess and assist members to help move them through the continuum of care by utilizing services and resources efficiently.
• Be part of a multidisciplinary team to continuously look for ways to improve processes and maximize health dollars for our members.

1. Provide members and health care providers with appropriate and timely prior approval. Complete post service reviews for medical necessity and/or experimental/investigational.
2. Provide precertification and continued stay reviews and support to members while located in an acute health care facility, skilled or other facility level of care or home health care admissions. Assist facility to ensure development and facilitation of a timely discharge plan and make referrals to Case Management for ongoing needs.
3. Work with health care provider staff in a courteous and professional manner in gathering medical information and facilitating discharge planning to ensure accurate diagnosis codes for documentation and reporting purposes.
4. Influence, collaborate and negotiate with providers in an open, direct, and supportive manner to resolve conflicts, utilization review issues and alternative treatment setting options.
5. Process utilization management requests by utilizing clinical knowledge and expertise in interpreting medical policy, medical criteria (InterQual), and benefit information for internal/external customers.
6. Interact with Wellmark Medical Directors and Physician Reviewers, as appropriate for services that do not meet medical criteria.
7. As a member of the interdisciplinary care team, collaborate with other clinical and nonclinical stakeholders, both internal and external to Wellmark, to provide optimal service and meet the needs of the member and coordinate care.
8. Document review processes and decisions accurately, consistently, and timely within the review documentation system by following the standard work guidelines and policies to support internal and external processes.
9. Meet both quality assurance and production metrics as established for the utilization management unit. Communicate approval and denial decisions to members and/or providers using both verbal and written communication.
10. Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to the Utilization Management Team.

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