Overview UTILIZATION MANAGEMENT - REGISTERED NURSE (FULL-TIME / REMOTE / HYBRID)
This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location. No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin. Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence.
Job Summary
The Utilization Management RN is responsible for the utilization management/review of claimants from PSE’s book of business.
Responsibilities Claim reviews: Pre-Claim, Concurrent Claim, and Post-Claim Reviews (Retro Reviews) as identified by claims analyst, bill audit staff, or Health Management
Responsible for UM-RN function of designated groups
Review and contact clinical staff at the provider for medical information to ensure the completeness of the medical record
Research plan language in the Employer Benefit Plan Document and make a clinical determination of coverage or no coverage
Coordinate sending cases out for medical review if required
Authorize services or denial of services based on the Employer Benefit Plan Document; handle all appeals
Assist with maintaining Quick Reference Guide for designated groups
Notify Case Manager of potential need for CM as appropriate
Provide vacation and overflow coverage for standard Pre-certification and Utilization Management staff
Assist with writing and updating policies and/or procedures related to the UM function
Other duties as assigned
Position Requirements Adherence to the Scope of Standards of Practice for RNs
Perform Utilization Management according to PSE standards and national standards for utilization management
Adherence and application of HIPAA regulations
Experience in utilization review, concurrent review and/or discharge planning
Ability to work collaboratively with the Health Management Team and the Claims Processing Team
Become familiar with Prairie States Enterprises’ Book of Business Health Care Plans
Become familiar with the Appeals Process for disputed claims
Become proficient in the use of applicable software systems including ACUITYnxt
Must be able to carry on conversations with medical providers and members to facilitate understanding
Effective communication skills including oral, nonverbal, and written
Strong organizational skills
Basic computer skills and ability to learn new computer programs
Cross-train to all aspects of Health Management; perform other tasks as required by Health Management
Position Qualifications BSN Required; RN current licensure in good standing
Minimum of 5 years of clinical experience
Past UM or CM experience in a clinical or hospital setting desirable
Strong competence in the use and understanding of the MCG guidelines for medical necessity
Strong competence with patient care management systems
Proficient computer skills: Word, Excel, Microsoft Outlook, keyboarding and data entry
Required Competencies Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals
Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure
Accountability/Results – Achieves and/or exceeds result-based goals that are specific, measurable, and timely
Teamwork – Demonstrates teamwork behaviors and contributes to department goals
Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations
Professional Growth – Takes ownership of one’s professional growth within one’s current position and at PSE
Physical Demands / Work Environment This is a sedentary position which requires sitting for long periods and extensive viewing of computer screens. Periodic movement within the office space is encouraged to counteract the sedentary nature of this position.
Benefits & Offerings Competitive compensation based on experience and a comprehensive benefit package including Medical, Dental, Vision, Life, STD/LTD, FSA, Paid Time Off, personal days, 401k with match, wellness and more. View the full-time benefits flyer for details. Opportunity for meaningful career growth within a results-driven company and a culture of ambition, integrity, empowerment, teamwork and a passion for personal and company success.
Application Instructions If this sounds like you and you’re seeking career growth with an exciting new path in overseeing the quality of health care for our clients and their members, please submit your cover letter and resume following the site instructions. Prairie States Enterprises – Equal Opportunity Employer.
Notes Referrals increase your chances of interviewing at Prairie States Enterprises, Inc. by 2x. We are not including extraneous job-search listings or unrelated postings in this description.