RN – Utilization / Care Management (UM/CM) Nurse
People. Passion. Purpose.
At P3 Health Partners, our promise is to guide our communities to better health, unburden clinicians, align incentives and engage patients.
We are a physician-led organization relentless in our mission to overcome all obstacles by positively disrupting the business of health care, transforming it from sickness care into wellness guidance.
We are looking for an Utilization / Care Management (UM) Nurse. If you are passionate about your work; eager to have fun; and motivated to be part of a fast-growing organization, then you should consider joining our team.
The UM Nurse is responsible for compliance with the Medical Management Program Description of P3 Health Partners regarding Utilization Review, inclusive of prior authorization, on-site and telephonic, concurrent and retrospective review, discharge planning and transitions of care to the appropriate level. The UM Nurse adheres to the standard operating procedures that support achieving the Quadruple Aim: improved outcomes, improved patient experience, improved clinician experience and decreased cost of care. The UM Nurse will integrate the functions of utilization review, discharge planning and resource management into a singular effort to ensure, based on patient assessment and best practice, that care is provided in the appropriate setting utilizing medically indicated, contracted resources.
- Promote the mission, vision and values of P3 Health Partners
Perform telephonic review of prior authorization, concurrent review and transition of care requests for appropriate care and setting, following guidelines and policies and approve services as per policy or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
Perform discharge planning functions in collaboration with the acute / post-acute facility and P3 Health Partners Medical Management stakeholders
Obtain additional clinical information from requesting provider or other sources when necessary for determinations
Complete medical necessity and level of care reviews for requested services using clinical judgment. Refer to Medical Directors for review depending on case findings
Collaborate with various staff within provider networks and Medical Management teams electronically or telephonically to coordinate care
Educate providers on utilization and Medical Management processes
Provide clinical knowledge and act as a clinical resource to non-clinical team
Enter and maintain pertinent clinical information in various Medical Management systems
Address gaps in care
Education & Experience:
- Graduate from an Accredited School of Nursing. Bachelor’s degree in Nursing preferred.
Minimum two years of clinical nursing experience, including a minimum of two years in a managed care/HMO organization.
Care management and utilization management experience preferred.
Proficient with computer and software programs (e.g.; Microsoft Word, Excel) and the Internet required.
Experience applying medical management treatment guidelines and nationally recognized criteria, such as InterQual / McKesson, MCG, or other practical management guidelines required.
Must be a self-starter, comfortable collaborating with physicians, hospital team members, patients and families; discussing appropriate levels of care that may be in conflict with requested service.
Ability to obtain and maintain current registration to practice as a Professional Nurse in the states where P3 has contracts.