• Utilization Review Nurse

    Job Locations US-NV-Las Vegas
    Posted Date 1 week ago(1/14/2019 1:36 PM)
    # of Openings
    Culinary Health Fund
  • Overview




    Looking for a way to influence the health and healthcare of many?


    If so, we’d love to hear from you! Our mission-driven organization is focused on theTriple Aim - Better Health, Better Healthcare and Lower Costs to individuals and their families who participate in our health plans.


    UNITE HERE HEALTH serves 90,000+ workers in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!



    Key Attributes:

    • Integrity - Must be trustworthy and principled when faced with complex situations
    • Ability to build positive work relationships - Mutual trust and respect will be essential to the collaborative relationships required
    • Communication - Ability to generate concise, compelling, objective and data-driven reports Teamwork Working well with others is required in the Fund'ss collaborative environment
    • Diversity - Must be capable of working in a culturally diverse environment Continuous Learning Must be open to learning and skill development. As the Fund�s needs evolve, must be proactive about developing new areas of expertise.



    The Medical Management department is participant focused and strives to provide the best possible care for the participants through Utilization Review and Utilization Management services, Care Coordination and Population Health Management.  The Medical Management department also assists participants in receiving care with specialists outside the service area when appropriate.  The Department is designed to ensure the delivery of high quality, cost efficient healthcare for our participants and families through coordinating care, providing detailed discharge plans, advising participants of different programs available and providing face-to-face and telephonic education.


    The Utilization Review Nurse is responsible for conducting utilization management activities in accordance with Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent and retrospective review activities. The Utilization Review Nurse promotes exceptional customer service by providing outreach to participant and families as well as providers as providers.  


    • Contributes to UM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities
    • Must become knowledgeable of URAC requirements for clinical staff for UM accreditation
    • Performs telephonic review for inpatient and outpatient services using InterQual, Milliman criteria or internal criteria
    • Collects only pertinent clinical information and documents all UM review information using the appropriate software system
    • Promotes alternative care programs and researches available options including costs and appropriateness of patient placement in collaboration with plan benefits
    • Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
    • Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues
    • Recommends, coordinates and educates providers regarding alternative care options
    • Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and clients discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement
    • Participates in UM program CQI activities
    • Communicates all UM review outcomes in accordance with the health plan procedures
    • Follows relevant time frame standards for conducting and communicating UM review determination
    • Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures
    • Identifies and communicates to the Outpatient Clinical Services Manager all hospital, ancillary provider, physician provider and physician office concerns and issues
    • Identifies and communicates to Outpatient Clinical Services Manager all potential quality of care concerns and patient safety
    • Serves as liaison for provider staff and the client
    • Maintains courteous, professional attitude when working with the Client’s staff, hospital and physician providers, and all ancillary providers
    • Identifies and communicate all catastrophic and high risk cases for case management referral;
    • Active participation in team meetings
    • Performs other duties as assigned within the scope of responsibilities and requirements of the job

    Years of Experience and Knowledge

      • Minimum 2 years of experience in utilization review, quality assurance, discharge planning or other cost management programs preferred.
      • Minimum 2 years directly related experience using InterQual or Milliman criteria or healthcare criteria preferred.
      • 2 years’ experience in hospital based nursing required. Medical-surgical care experience preferred for positions in medical management areasPerforms Essential Job Functions and Duties with or without reasonable accommodatio

    Education, Licenses, and Certifications

      • Unrestricted active RN or LPN License in the State of Nevada.
      • Willingness and ability to obtain a license in other States as may be required by the Fund

    Skills and Abilities

        • Microsoft Office skills (PowerPoint, Word, Outlook)
        • Microsoft Excel skills
        • Preferred fluency (speak and write) in Spanish
        • Excellent written and verbal communication skills
        • Excellent interpersonal skills – ability to express compassion and balance the emotions with business needs
        • Strong communication, documentation, clinical and critical thinking skills essential
        • Working knowledge of utilization management required
        • Strong problem solving and decisions making skills essential
        • Communicate clinical information to non-clinical individuals


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