Utilization Management RN

 

Wexford Health Sources, one of the nation's leading innovative correctional health care company, provides clients with experienced management and technologically advanced services, combined with programs that control costs while ensuring quality.  For nearly two decades, Wexford Health has consistently delivered proven staffing expertise and a full range of medical, behavioral health, pharmacy, utilization management, provider contracting, claims processing, and quality management services.

At Wexford Health our philosophy is that health care should not be considered a luxury for anyone.  We simply care for those in need and the corrections environment is our venue.

Wexford Health has an exceptional opportunity for a

Utilization Management Nurse (RN)

to join our team of healthcare professionals at our

Regional Office in Columbia, MD.

We’re proud to offer a competitive benefits package including:

  • Annual review with performance increase
  • Generous paid-time off program that combines vacation and sick leave
  • Paid holidays
  • Comprehensive health insurance through Blue Cross Blue Shield
  • Dental and Vision insurance
  • 401(k) retirement saving plans
  • Company-paid short-term disability
  • Healthcare and dependent care spending account

POSITION SUMMARY

The Utilization Management Nurse (RN) ensures cost effective outcomes while maintaining a focus on quality care for inpatient and/or outpatient services. He/she monitors on-going medical needs and services by engaging in the following: evaluating medical necessity, appropriateness and efficient use of Health Care Services for inpatient hospitalizations and/or outpatient procedures, working closely with physicians, hospital utilization management and correctional facilities to provide quality, cost-effective care at the level most appropriate to the inmate-patient; and providing reports and recommendations to medical and facility staff for improved utilization of resources.

DUTIES/RESPONSIBILITIES

OUTPATIENT SERVICES:

1. Reviews requests for outpatient/onsite services.

2. Reviews and maintains all contractual turnaround times.

3. Obtains necessary clinical information, history, criteria, and present findings to UM Medical Director for inpatient and/or outpatient review.

4. Participates in weekly discussions with site providers and UM Medical Director.

5. Review reports to monitor appropriateness and accuracy of the entry process.

6. Verify response back to schedulers with results of referral reviews within contractual time frame.

7. Work with schedulers to ensure that appointments are obtained and patients are seen within specified date range.

8. Provide site and providers with authorization number.

9. Pre-certify specific surgical cases.

10. Assist Team with contractual issues and updates.

ADDITIONAL DUTIES AND RESPONSIBILITIES:

1. Assist callers with questions, refer when appropriate.

2. Provide overview of Utilization Management purpose and function to new Health Care Unit Administrators and other site personnel as requested by the Director, Utilization Management.

3. Assist with orientation of new UM staff and site staff as indicated.

4. Work with Medical Directors to identify areas of concern and quality improvement.

5. Work with Director of Utilization Management and other UM staff on special projects.

6. Actively participate in Utilization Management staff meetings.

7. Collect data to monitor facility compliance to Company standards and policies.

8. Be knowledgeable of Department of Correction Policy/Procedures and Contractual Agreements with providers

The duties and responsibilities outlined herein are for payroll purposes only; employees may be assigned other duties as required.

ENVIRONMENTAL CONDITIONS

Standard office environment.

 

LICENSING: Current Registered Nursing license within the state.

CERTIFICATION: Current CPR certification.

EDUCATION: Graduate from an accredited School of Nursing

PREFERRED EXPERIENCE:

  • Prefer a minimum of two (2) years of clinical experience
  • Correctional experience, a plus

OTHER PREFERRED KNOWLEDGE, SKILLS AND ABILITIES:

  • Self-directed
  • Strong interpersonal, and verbal and written communication skills
  • Demonstrated experience meeting multiple deadlines.
  • Ability to competently manage multiple priorities simultaneously
  • Ability to work in a stressful environment
  • Must be a "team-player" as this position requires daily coordination with other coworkers.

EOE/M/F/D/V