• Job Description

  Req#: oQ7fwfws?nl=1

  Medical Associates is looking for a Utilization Management Nurse to join our Health Care Services team!u00A0
  
  Schedule: Primary schedule will be Monday through Friday 8:00am to 5:00pm, 40 hours/week with flexibility.u00A0After training, there is o pportunity for work from home if desired!

  Location:u00A0Training is in-person at Medical Associates Health Plans, 1605 Associates Drive, Dubuque, IA 52002

  Benefits Package Includes:

  • Single or Family Health Insurance with discounted premium rates for wellness program participation.
  • 401k with immediate matching (50% on the dollar up to 7% of pay + additional annual Profit Sharing)
  • Flexible Paid Time Off u00A0Program (24 days off/year)
  • Medical and Dependent Care Flex Spending Accounts
  • Life insurance, Long Term Disability Coverage, Short Term Disability Coverage, Dental Insurance, etc.

  What You Will Be Doing:

  • Review requests from providers or members for approval of procedures, medications, durable medical and/or services prior to delivery of the service.
  • Utilize established screening criteria to ensure patients get the correct treatment from the resources that are available at the most cost effective level to meet their needs.u00A0
  • Facilitate options and services for meeting individualsu2019 health needs with the goal of decreasing fragmentation, duplication of care and enhancing quality, costu2011effective clinical outcomes.
  • Review of hospital and skilled admissions to justify continued care is medically necessary per Health Plan established guidelines.

  Essential Functions & Responsibilities:

  1. Conduct reviews inclusive of physician referrals, medication reviews, admissions, utilization review updates, investigating alternatives to hospitalization such as home health care and durable medical equipment, utilizing the assessment process by obtaining pertinent patient history and accurate vital data, anticipating patient and family needs, working with the Health Choice Claims and Membership Services to determine benefit eligibility,u00A0facilitating crisis intervention, sharing information with cou2011workers and documenting accurately.u00A0 Utilize established screening criteria to determine medical necessity of requested authorizations.u00A0 Refer patients to case management nurse or health coach as appropriate.
  2. Facilitate outu2011ofu2011plan referrals, outu2011ofu2011area urgent and emergent care for enrollees and provider offices and provide necessary information to Medical Director on specified referrals. Communicate decision to enrollees, providers, and facilities per established policies.
  3. Work collaboratively with internal and external staff, in determining extent of benefits and coverage for services being coordinated.u00A0 Document authorizations, denials, cost savings and other outcome measurements.
  4. Act as a resource for the enrollee, provider offices, and other MAHP departments.u00A0 Perform retrospective review to determine coverage of hospitalizations, and outpatient services.u00A0 Communicate with enrollees regarding the use of managed care systems and participate in answering enrollees and providers inquiries.u00A0
  5. Assist in preparations for external review/regulatory agencies.
  6. Complete all other assigned projects and duties.

  Knowledge, Skills and Abilities:
  
  Experienceu00A0- Three years to five years of similar or related experience.
  
  Educationu00A0- Valid RN nursing license is required.u00A0

• About the company

  We believe...this is the way healthcare should be.

Notice