Position Summary:
The Utilization Management Coordinator RN is responsible for implementing medical utilization management functions for fully-insured and self-insured groups, including Medicare Advantage in all service areas. Medical Utilization management functions include prior authorization, inpatient care management, outcome data, file audits, medical criteria review, and behavioral health/ substance use disorder management. Staff will be assigned to specific functions based on staff skill and department needs. Adheres to all mandated guidelines, including URAC, Department of Insurance, Department of Labor, and state and federal regulations.

Qualifications:
EDUCATIONAL REQUIREMENTS
College Diploma in Nursing

CERTIFICATION & LICENSURE REQUIREMENTS
IL RN License REQUIRED upon application
Registered Professional Nurse (RN) License Illinois upon hire.

EXPERIENCE REQUIREMENTS
Two (2) years Healthcare/Medical field

SKILLS AND KNOWLEDGE
Demonstrates an aptitude for data management and information systems, financial applications and administrative planning. High degree of computer literacy with medical and office software. Ability to handle high-volume digital and telephone work. Must be able to work independently on a daily basis, as well as part of the Health Alliance team. Ability to change and adapt daily to the changes in the managed care environment and products. Excellent communication, organization, and time management skills required. Ability to assess situations and make appropriate decisions based on benefit plans, Medical Policy and Procedures, regulatory requirements, and the most cost-effective care at the most appropriate setting.

Essential Functions:

• Acts as a resource to other departments regarding utilization management matters, coverage guidelines, and assisting as needed with clinical issues.
• Performs prior authorization process, inpatient review, and retrospective review of requested services or pended claims based on clinical documentation submitted, established medical necessity criteria, organizational guidelines, and plan benefits within established timeframes and in accordance with department policy.
• Assists with Inpatient Care Coordination oversight and performs inpatient reviews to coordinate care with providers, facilities, families and to ensure medical necessity, timely discharge, and indicated referrals, utilizing current Health Alliance criteria (When Applicable to team needs).
• Refers members to the care coordination department when on-going needs are evident.
• Works closely with providers and others to coordinate care and best support member's needs.
• Explores opportunities for members to receive quality, cost-effective care utilizing alternative settings or community agencies.
• Ensures all authorization approval or denial documentation is complete and includes all review materials, plan materials, and clinical criteria needed to make the decision.
• Forwards all appeals to Member and Provider Solutions Department staff and assists, as needed, in compiling data and documenting the sequence of events thoroughly.
• Provides clear, concise, accurate and timely documentation on forms and in electronic systems as appropriate per departmental standards.
• Provides written responses to members and physicians as needed in a professional, accurate and timely manner.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.

Effective September 20, 2021, the COVID 19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted.