Utilization Management Nurse

Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

We offer Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We’re also committed to boosting the health of our community through outreach, education, and events. Founded over 35 years ago, Jefferson Health Plans continually develops new ways to encourage better health outcomes and has received national recognition for our innovations in managed care.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of JHP and why you will love it here:

• Competitive Compensation Packages including 401(k) Savings Plan with Company Match and Profit Sharing
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off
• Impact on the communities we service

We are seeking a talented and enthusiastic Utilization Management Nurse to join our team!

The nurse works independently under general supervision to assure cost effective, quality Utilization Management in the reviews clinical information provided by facilities and communicates UM determinations maintaining timeliness.

As the Utilization Management Nurse, your daily duties may include:

• Responsible for the effective and sufficient support of Utilization Management activities to include concurrent, prospective and pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.
• Perform medical necessity review for clinical services or medical supplies.
• Request and review medical records to identify appropriate setting.
• Function as a liaison between providers, members, and other internal departments.
• Maintain departmental and regulatory timeframes for decisions.
• Use an established set of criteria, evaluates and authorizes the medical necessity of some inpatient and outpatient services.
• Issue letters to provider and member if the service does not meet pre-certification criteria and may issue denial letters.
• Work with management team to achieve departmental goals.
• Successful and timely completion of assignments in accordance with departmental and company operational objectives and seek feedback on performance.
• Maintain detailed knowledge of the status of all assignments and routinely update the management team as appropriate.
• Perform all other duties as assigned.

Qualifications

• Bachelor’s degree preferred.
• Licensed Registered or Practical Nurse with an active license to practice professional nursing in the Commonwealth of Pennsylvania required.
• Required minimum 2 years medical/surgical, utilization review and/ or emergency room experience

Skills, We Value:

• Present polished professional image.
• Demonstrate knowledge of HMO delivery systems.
• Demonstrate ability to work and communicate effectively with co-workers, members and providers at the owner institutions.
• Demonstrate excellent organizational skills and ability to competently handle multiple responsibilities at one time.
• Demonstrate excellent telephone and verbal/written communication skills.
• Demonstrate computer proficiency with Word, Excel and other applications

Job Type: Full-time

Pay: From $80,982.73 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Medical specialties:

• Medical-Surgical

Schedule:

• 4x10
• 5x8
• Day shift
• Monday to Friday

Ability to Relocate:

• Philadelphia, PA: Relocate before starting work (Required)

Work Location: Remote