COPE Health Solutions is hiring a Utilization Manager, Registered Nurse, who will assess member needs and identify solutions that promote high-quality, cost-effective health care services. You will manage requests for medical services, render clinical determinations in accordance with policies and regulations, and coordinate with physicians and other stakeholders to ensure appropriate care delivery.
What You'll Do
- Conduct comprehensive reviews of service requests, including clinical record reviews and interviews.
- Examine standards to ensure medical necessity and appropriateness of admissions, treatment, level of care, and lengths of stay.
- Perform prior authorization and concurrent reviews to confirm extended treatment is medically necessary and in the right setting.
- Ensure compliance with state and federal regulatory standards and organizational policies.
- Identify opportunities for alternative care options and contribute to patient-focused discharge plans.
- Review covered services according to plan benefits, evidence-based criteria, and regulatory requirements.
- Provide recommendations for improvement regarding departmental processes and procedures.
- Maintain current knowledge of organizational or state-wide trends affecting member eligibility.
- Improve clinical and cost-effective outcomes through member education, care management, and team collaboration.
- Provide input for the design and development of effective case management and customer service processes.
- Maintain accurate records of all care management activities, including progress notes and communications.
- Participate in approval decisions for out-of-network services.
- Provide case direction and assistance to ensure quality service delivery.
- Keep current with all health plan changes and updates through training and educational materials.
- Issue Determinations, Notices of Action, and other communications to members and providers.
- Review, evaluate, and determine the appropriateness of requests using clinical practice guidelines.
- Evaluate and analyze care and utilization trends to identify opportunities for better care coordination.
What We're Looking For
- A Compact Licensed RN.
- An Associate degree in nursing as a minimum requirement.
- Knowledge of Medicare and Medicaid regulations.
- Excellent organizational, time management, interpersonal, and communication skills.
- Working knowledge of Microsoft Excel, PowerPoint, and Word.
- Strong typing skills.
- Knowledge of Milliman criteria (MCG).
- For Utilization Management: Experience must be with a Managed Care Organization or Health Plan.
- Experience working with community-based organizations in underserved communities.
Nice to Have
- California and New York State RN license.
- A Bachelor’s degree in nursing.
Technical Stack
- Microsoft Excel
- Microsoft PowerPoint
- Microsoft Word
Team & Environment
This role reports directly to the Medical Management team.
Benefits & Compensation
- Compensation range: $90,000-$110,000.
Work Mode
This is a fully remote position.
COPE Health Solutions is an equal opportunity employer.
