Utilization Management Nurse

Essential Responsibilities/Accountabilities: This job is hybrid and requires some weekly in office work Promote the use of evidence-based care through extensive use of NCCN Guidelines®, Clinical Trials.gov, McKesson Clear Value Plus, and the use of our COE networks Assess new patients’ need for treatment at a Center of Excellence Facility Document all activities in electronic medical record (EMR) Perform all duties efficiently while keeping cost containment and patient centric quality care a priority Effectively communicates the status of patient activities through the use of PA’s, Notification Forms, email and/or telephone. Understands and makes decisions based upon benefit plan language. Assists with organizing services across provider lines, between people and systems to affect optimal patient outcomes, achieve continuity of care and reduce costs Serves as a utilization management resource to determine appropriateness of treatment plan, level of care Maintains a working knowledge of Medicare and private insurance companies and ensures that quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting data to appropriate person(s) and/or department(s) Performs other duties as assigned and accepts new tasks as opportunities for growth Collaborates with health care team members to develop a multidisciplinary plan of care and sets patient-centered goals for patient/families Facilitates and/or participates in discussions that provide ongoing evaluation of interdisciplinary intervention, goal attainment, and treatment plan revision Knowledgeable about the patient’s financial status, diagnosis and discharge needs to develop the plan of care Also maintains an awareness of the patient’s psychosocial situation, including identification of potential barriers which may impact patient compliance and facilitates the coordination of referrals as appropriate Provides ongoing communication with patients, families, medical staff, care givers and third-party payers, to include utilization assessment for pre-authorization Communicate with providers to ensure clinical documentation supports the service and level care provided to the patient Work cohesively with triage center Intake Coordinators and Oncology Nurse Experts Additional Responsibilities: Maintain integrity of company image, philosophy, and methods in all communications Represent CancerCARE and health plans by being professional at all times. Job Qualifications (Knowledge, Skills and Abilities): RN with active license (Compact state license preferred) Excellent relationship-building skills Excellent verbal and written communication skills Exemplary computer and technical skills. Feel comfortable with learning new technology and troubleshooting technology Proficiently type directly into an electronic medical record while obtaining information telephonically from the patient Strong organizational skills with the ability to multi-task Proficient in Microsoft Office Strong analytical and problem-solving skills Self-motivated Able to work independently and in a team environment Education and Experience: RN with active license; Compact State license and Oncology experience preferred Management experience desired Must have familiarity with reviewing medical records Experience in or knowledge of insurance, TPA, or medical stop-loss and reinsurance industry preferred Must have Oncology/NCCN experience Job Type: Full-time Pay: $90,000.00 - $95,000.00 per year Benefits: 401(k) Employee assistance program Free parking Life insurance Schedule: Day shift Monday to Friday Experience: Oncology: 3 years (Required) License/Certification: Compact State Nurse License (Required) Work Location: Hybrid remote in Rockwall, TX 75087