Utilization Management Nurse (RN) - Case Management - Day (Temporary)

Location: WellSpan Health, York, PA

Schedule: Full Time

Sign-On Bonus Eligible

Remote/Hybrid

Temporary

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Schedule and Location

Temporary Role to last approximately 6 months

Full Time: 40 Hours/Week

Hours: Monday - Friday 8am - 4:30pm

Weekend Rotation Required

This is a remote position where the ideal candidate would be located in South Central Pennsylvania or in Northern Maryland, but exceptional candidates located outside of the service area may be considered. Occasional travel required within WellSpan's geographic footprint.

General Summary

Performs a variety of reviews and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality health care. Provides leadership in the integration of utilization management principles throughout the System. Responsible for screening patients for care management programs, including bundles and complex care management.

Duties and Responsibilities

Essential Functions:

• Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.

• Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under utilization. Refer cases to Medical Director that require additional expertise.

• Liaisons between third party payors and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy.

• Assists the patient care team with the identification and coordination of alternative treatment settings which will provide appropriate care, maintain quality of care and reduce cost.

• Identifies conditions which require case management across the continuum. Collaborates with the members of the patient care team to identify interdisciplinary needs. Refer to appropriate care management or disease management program.

• Assists with the collection and analysis of utilization patterns and denied cases.

• Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).

Common Expectations:

• Prepares and maintains appropriate documentation as required.

• Maintains established policies and procedures, objectives, quality assessment and safety standards.

• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

• Prepares and presents utilization data analysis as required.

• Develops and initiates educational programs regarding utilization management principles.

• Attends meetings as required.

Required for All Jobs:

• Performs other related duties as identified.

• WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program.

• WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

Physical Demands:

• Standing - Occasionally

• Walking - Occasionally

• Sitting - Frequently

• Reaching - Rarely

• Talking - Frequently

• Hearing - Frequently

• Repetitive Motions - Occasionally

• Eye/Hand/Foot Coordination - Occasionally

Qualifications

Minimum Education:

• Associates Degree Required

Work Experience:

• 3 years Relevant experience. Required

• Experience in utilization management, case management, or clinical nursing specialty Preferred and

• Working in Human Resources with specific responsibility for leave of absence administration or management. Preferred

Licenses:

• Licensed Registered Nurse Upon Hire Required or

• Registered Nurse Multi State License Upon Hire Required

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You’re unique and you belong here.

At WellSpan Health, we are committed to treating all applicants fairly and equitably, regardless of their job classification. If you require assistance or accommodation due to a disability, please reach out to us via email atemployment@wellspan.org. We will evaluate requests for accommodation on a case-by-case basis. Please note that we will only respond to inquiries related to reasonable accommodation from this email address. Rest assured, all requests for assistance or accommodation are handled confidentially, allowing applicants to share their needs openly and honestly with us.

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.