Utilization Management RN

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🔥 4 minutes ago

🇺🇸 United States – Remote

💵 $34 - $38 / hour

⏱ Part Time

🟢 Junior

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HealthCare Strategies

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 1982

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 B2B

Healthcare • Healthcare Insurance • B2B

HealthCare Strategies is a medical cost-management company that provides predictive care management, virtual nursing and outreach, and medical management services to reduce plan costs and improve member outcomes. It serves self-insured employers, labor funds and coalitions, third-party administrators (TPAs), government and commercial health plans, and provider groups. HCS uses AI-driven analytics and a consumer health platform to identify emerging health risks earlier, connects members with care managers and virtual nurses, and offers utilization management, precertification, case review, and independent review services. The company emphasizes measurable improvements in health outcomes and cost reductions and is based in Columbia, MD.

📋 Description

• Collect personal and clinical information on participating Plan members • Provide patient education services • Render initial determinations of medical appropriateness for communication to the health benefit plan • Identify individuals whose health and/or expenses may be positively affected through Large Case Management • Perform telephonic clinical assessments • Obtain information from healthcare providers, patients, or families regarding planned procedures, admissions, continued stays, or discharge plans • Interpret nationally recognized criteria to support recommendations for inpatient and outpatient services • Identify and refer individuals for Case Management • Document calls completely, accurately, and promptly in the computer system • Follow policies and procedures for confidential materials and patient-specific information • Answer calls related to medical services and determine whether prior authorization is required • Retrieve and acknowledge voicemail messages requesting medical services • Complete medical necessity reviews and communicate outcomes to providers within appropriate time frames • Provide educational materials and direct callers to community services when indicated • Provide coverage for professional colleagues

🎯 Requirements

• Active, unrestricted RN Compact License • Minimum internet speeds of 25Mbps download and 25 Mbps upload • 1+ years experience in hospital setting • Strong verbal communication skills • Problem-solving and decision-making skills • Ability to carry out detailed written or verbal instructions independently • Proficiency with Microsoft Office Suite (Outlook, Word) • 1+ years previous UM experience (preferred) • Experience using InterQual criteria (preferred)

🏖️ Benefits

• Work from your home office • Part-time schedule of 20 to 25 hours per week • Monday–Friday schedule • Core office hours of 9am–6pm ET • Coverage for professional colleagues

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