Job Description - Lead Utilization Management, RN
- Location : Remote / Work From Home
- Salary : $37 - $114 / HOUR
- Job Type : FULL_TIME
Imagine360 is currently seeking a Lead Utilization Management, RN to join the team! The Lead Utilization Management, RN is responsible to utilize their nursing education, clinical, and professional experience to provide UM services at a high level and provide oversight to the Utilization Management Nurses.
Position Location: 100% Remote
Responsibilities include but are not limited to:
- In addition to completing initial clinical review process by adhering to the utilization management policies and procedures with a high level of quality, the Lead Nurse will:
- Provide clinical and process oversight for staff assigned to utilization management cases
- Acts as role model within a team setting to provide positive outcomes for participants, peers, and overall operations.
- Distribute approved education to UM Nurses
- Collaborate with Supervisor, Utilization Management to:
- Review & communicate determinations for PTO requests
- Manage and coordinate daily & weekly staffing needs
- Review and communicate determinations for staff requested PTO/Flex
- Communicate with team, MIS Supervisor and/or assigned staff to publish PTO/Flex schedules to UM team in a timely manner
- Implement education opportunities for the Utilization Management Nurses
- Assist with triaging of cases
- Participates in Quality Management program in the following ways (10%):
- Assist in Quality Assurance review/Chart audit process for reporting UM staff members
- Reviews QA results to develop educational opportunities for the UM Staff
- Reviews policy and procedures as required and recommends changes to the Supervisor and Manager
- Collects, analyzes and reports data of quality improvement projects and other data related to utilization services
- Communicates effectively with members, employers, Healthcare providers, vendors, peers, and customers
- Attend scheduled and periodic meetings, training and other job specific events as required
- Adhere to established internal & external regulations regarding Department of Labor, HIPAA, ERISA and organization policy and procedure.
- Complete duties in accordance with scope of licensure and certifications held or requested
- Other duties and special projects as assigned.
Areas of Responsibility Scope of Practice:
- In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making and patient education. The scope of practice includes, but is not limited to:
- Evaluating clinical data
- Assessment and evaluation of the acquired clinical date to assess for appropriateness of treatment based on Imagine360 clinical guidelines,
- Coordination of treatment plans, interventions, and outcome measurement
- Rationale for the effects of medication and treatments
- Provide patient education and educational resources.
- Accurately report:
- Administration of medication and treatments
- Client response
- Contact with other health care team members.
- Respect the client's right to privacy by protecting confidential information.
- Promote and participate in education and counseling to a participant based on health needs.
- Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner.
- The Team Lead, Case Management will have knowledge and practice the core components of Case Management that include:
- Case Management Concepts
- Principles of Practice
- HealthCare Management & Delivery
- Healthcare Reimbursement
- Psychosocial Aspects of Care
- Rehabilitation
- Professional Development & Advancement
- Quality and Outcomes Evaluation and Measurement
- Ethical, Legal and Practice Standards
Required Experience / Education:
- Nursing degree from an accredited school of nursing, college or university.
- Minimum of 1 year experience in utilization review services or transferable nursing skills
Licenses or Certifications: Must maintain an unrestricted Registered Nurse License in eNLC compact state and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license as required to perform the job functions of the organization, if driving is required for company business.
What can Imagine360 offer you?
- Multiple Health Plan Options, including a 100% Employer Paid Benefit Options
- 100% Company paid employee premiums for Dental, Vision, STA, & LTD, plus Life Insurance
- Parental Leave Policy
- 20 days PTO to start / 10 Paid Holidays
- Tuition reimbursement
- 401k Company contribution
- Professional development initiatives / continuous learning opportunities
- Opportunities to participate in and support the company's diversity and inclusion initiatives
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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.
Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation*
