Job Description

Provide utilization management review and support to members and health care providers. Utilize clinical knowledge and expertise to interpret and appropriately apply medical policy, medical necessity criteria (InterQual), and benefit information and provide consultation and responses to utilization management requests. Proactively assess and assist members to help move them through the continuum of care and to utilize services and resources efficiently. Function as part of a multi-disciplinary team to continuously look for ways to improve processes and maximize health dollars for our members.

Qualifications

Required:

• Completion of an accredited nursing program or licensed practical nursing program.
• Active and unrestricted RN or LPN license in Iowa or South Dakota. Individual must be licensed in the state in which they reside.
• 4+ years of diverse clinical experience (e.g. acute care, outpatient, home health, etc.) that reflects 4+ years of direct clinical care to the consumer. Experience in utilization management or health insurance setting beneficial.
• Previous experience working independently and managing an assigned caseload.
• Strong verbal communication skills; influences action and facilitates crucial conversations regarding care with members, physicians, and care facilities.
• Strong written communication skills, including accurate documentation of events within the care management platform; ensures quality and consistency by following guidelines and processes.
• Commitment to service excellence and member advocacy; uses critical thinking and problem-solving skills to anticipate and act on member/provider needs.
• Resourceful self-starter who demonstrates strong understanding of resources, processes, and guidelines. Able to make independent decisions or recommendations under ambiguity.
• Ability to organize and manage multiple priorities in a dynamic work environment where quality and/or production goals are measured. Commitment to timeliness, follow up, accuracy and attention to detail. Flexible and adapts to change.
• Develops collaborative relationships with peers, team members and stakeholders; viewed as a trusted partner.
• Maintains courtesy and professionalism when engaging with members and providers, internal and external stakeholders.
• Strong technical acumen; learns new systems quickly – e.g., Microsoft Office, clinical documentation platforms, etc.

_ Preferred:_

• Active and unrestricted RN license in Iowa or South Dakota.

Additional Information

a. Provide members and health care providers with appropriate and timely prior approval (services, procedures, Wellmark Health Plan of Iowa Out of Network Referrals) by obtaining medical information necessary to make a clinical determination based on appropriate medical policy or criteria. Complete post service reviews for medical necessity and/or experimental/investigational.

b. Provide precertification and continued stay reviews and support to members while located in an acute health care facility, skilled or other facility level of care or home health care admissions. Assist facility to ensure development and facilitation of a timely discharge plan and make referrals to Case Management for ongoing needs.

c. Work with health care provider staff in a courteous and professional manner in gathering medical information and facilitating discharge planning to ensure accurate diagnosis codes for documentation and reporting purposes. Influence, collaborate and negotiate with providers in an open, direct, and supportive manner to resolve conflicts, utilization review issues and alternative treatment setting options.

d. Process utilization management requests by utilizing clinical knowledge and expertise in interpreting medical policy, medical criteria (InterQual), and benefit information for internal/external customers within the timeframes described in the requirements. Interact with Wellmark Medical Directors and Physician Reviewers, as appropriate for services that do not meet medical criteria.

e. As a member of the interdisciplinary care team, collaborate with other clinical and nonclinical stakeholders, both internal and external to Wellmark, to provide optimal service and meet the needs of the member and coordinate care.

f. Document review processes and decisions accurately, consistently, and timely within the review documentation system by following the standard work guidelines and policies to support internal and external processes, including documentation of potential avoidable days/ admission when medical necessity criteria are not met. Meet both quality assurance and production metrics as established for the utilization management unit. Communicate approval and denial decisions to members and/or providers using both verbal and written communication.

g. Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to the Utilization Management Team.

h. Other duties as assigned.

Must be flexible and have the ability work weekend and/or holiday hours when needed on a rotational basis.

Remote Eligible: You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other ‘moments that matter’ as well.

An Equal Opportunity Employer

The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.

Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us atcareers@wellmark.com

Please inform us if you meet the definition of a "Covered DoD official".

Remote Eligible: You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other ‘moments that matter’ as well.

An Equal Opportunity Employer

The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.

Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us atcareers@wellmark.com

Please inform us if you meet the definition of a "Covered DoD official".