Utilization Management Nurse

** While this role is remote, the candidate will be required to travel locally on occasion to hospitals and facilities.**

Our mission is Better Health. Our passion is helping others.

What's Your Why?

• Are you looking for a career opportunity that will help you grow personally and professionally?

• Do you have a passion for helping others achieve Better Health?

• Are you ready to join a growing team that shares your mission?

Why Join Our Team: At Better Health Group, it's our commitment, our passion, and our culture that sets us apart. Our Team Members make a difference each and every day! They support our providers and payors, ensuring they have the necessary tools and resources to always deliver best-in-class healthcare experiences for our patients . We don't just talk the talk - we believe in it and live by it. Be part of a team that shares your passion and drive, and start living your purpose at Better Health Group.

Summary/ Objective:

Health Services Utilization Management Nurse assists all partnered practices by providing a multi-faceted approach to managing requests for medical services while ensuring services are medically appropriate and necessary through the use of evidence-based clinical guidelines and provider input. Responsible for ensuring the receipt of high-quality, cost-efficient medical outcomes for those Patients identified as having the need for Inpatient Care and/or Outpatient procedures.

Essential Functions and Responsibilities:
  • Promote the mission, vision, and values of the organization.
  • Communicate and collaborate with PCP Office and Office Champion as appropriate.
  • Assesses, plans, implements, and monitors a comprehensive plan of care for patients with any admission criteria primarily but not limited to:
    • COPD/CHF/ESRD/DM/Wounds,
    • Patients with more than 10 days LOS, and/or
    • Frequent Flyers
  • Communicate and collaborate with the respective Hospital Discharge Planner, Attending Hospitalist, and/or PCP to review and discuss the case
  • Review Medical Necessity for Inpatient admissions, Establish collaboration with Hospitalists and payers to collaborate on outcomes
  • Review Clinical information for concurrent reviews, extending the Length of Stay (LOS) for Inpatients as appropriate.
    • Identify Admission to be reviewed within 24 to 48 hours of Admission to a facility and establish a Discharge Plan.
    • Continue Stay review - for Patients with LOS higher than 10 days at the Hospital or Long Term Acute Care (LTAC)/ Inpatient Rehab (IPR) cases.
    • Identify Patients with possible discharges to LTAC/IPR and communicate information to the CMO or Physician Consultant.
    • Identify Inpatient cases to be escalated to CMO or Physician Consultant where Observation Stay could have been used so Peer-to-Peer occurs with the Hospitalist.
  • Transplant Case Follow-up
    • Educate all Patients with Complex Illnesses to ensure that they are fully aware of their Plan of Care
    • Establishing Care Management accountabilities and holding those resources accountable
    • Engaging the Patient and provider care team in Plan of Care discussions
    • Patient (family) engagement
  • Skilled Nursing Facility review
    • Communicate daily with the SNF admission department and Physical/ Occupational Therapy (OT) personnel regarding current patient status, discharge planning, and outcomes
    • Initiate ongoing communication with SNF-ist, Social worker, and patient's family to assess discharge needs.
    • Communicate with PCP to ascertain their plans for a timely discharge. Review the patient's previous Level of Function.
    • Cooperate with insurance companies, based on information received.
    • Ensure that the quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the CMO and/or Physician Consultant.
  • Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
    • Promote improved Quality of Care and/or Life.
    • Promote cost-effective medical outcomes.
    • Prevent Hospitalization when possible and appropriate.
    • Promote decreased length of hospital stays when possible.
    • Provide for Continuity of Care.
    • Assure appropriate levels of care are received by Patients.
  • Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
  • Maintain accurate records in the company database of all interventions and provide timely verbal communication with the CMO and/or Physician Consultant.
  • Assist with the preparation of quarterly summary reports.
  • Support the Health Services department on Quality Assurance (QA)/ Quality Initiatives (QI).

  • At least 2 years of Utilization Management experience
  • Previous training and demonstrated competence in negotiations, Quality Assurance, and Case Management outcomes.

Special Licenses or Certifications:
  • Proof of successful completion of educational requirements for a Nurse as defined by the state of Oklahoma as well as proof of such licensure in good standing. (Multi-state preferred. Will have 90 days to obtain)
  • Complex Case Management (CCM) certification is a plus.
  • Valid Oklahoma Driver's License and vehicle insurance

Key Attributes:
  • Has a contagious and positive work ethic, inspires others, and models the behaviors of our core values and guiding principles
  • An effective team player who contributes valuable ideas and feedback and can be counted on to meet commitments
  • Can work within our Better Health environment by facing tasks and challenges with energy and passion
  • Pursues activities with focus and drive, defines work in terms of success, and can be counted on to complete goals
  • Demonstrated ability to handle data with confidentiality
  • Demonstrated ability to effectively and clearly present information through the written word or interpretation of data, to influence or persuade others through oral presentation in positive or negative circumstances, and to listen well

Skills, Abilities and Professional Competencies:
  • Computer literacy on Google Suite, Excel, Microsoft Office products, proprietary Health Management system, hospital EMRs, and Health Plan portals.
  • Excellent relationship management skills.
  • Ability to document in Electronic Database systems.
  • Demonstrated ability to solve complex, multifaceted, and emotionally charged situations.
  • Ability to function with minimal supervision.
  • Ability to successfully manage conflicts, negotiating "win-win" solutions.
  • Strong organizational, task prioritization skills
  • Detail oriented
  • Thorough documentation
  • Patient advocacy focus
  • Empathy

Supervisory Responsibility:
  • Utilization Management Nurse will report to the Director of Utilization Management

Work Environment:
  • Utilization Management Nurse operates remote in Oklahoma with occasional travel to Hospitals
  • This job operates in a professional office environment. This role routinely uses standard office equipment such as computers and phones

Physical Demands:
  • Ability to drive from facility to facility on a PRN basis
  • Ability to stand for extended periods of time
  • Ability to spend an extended amount of time facing a computer screen.

Position Type/ Expected Hours of Work:
  • This is a full-time position and core hours of work and days are Monday to Friday 8:00 a.m. - 5:00 p.m.
  • Extended hours to accommodate urgent and emergent tasks will be expected .

  • Mileage to and from home/work to other locations will be compensated at company rates
  • Fees incurred for parking will be compensated with receipts provided

  • At least monthly travel to Corporate or Regional Offices may be required for training or meetings.

Compensation & Benefits:

We offer a compensation w/bonus and a comprehensive benefits package:
  • Medical, dental, vision, disability, and life
  • 401k, with employer match
  • Paid time off
  • Paid holidays

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for their job. Duties, responsibilities, and activities may change at any time with or without notice.

We're an equal-opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.