Job Description

Select Health is a community health plan serving more than 1 million members. Select Health’s line of businesses (LOB) includes Medicare, Medicaid, FEHB, Marketplace Qualified Health Plans, fully funded and self-funded Commercial plans. Utilization Review nurses at Select Health proactively oversee inpatient and outpatient utilization to assure that care related to health insurance benefits is at the right time, right place, right provider, right level of care and medically necessary. Essential Functions: Reviews and investigates medical record and applies clinical expertise to assure appropriate benefit utilization, Uses in-depth knowledge of medical procedures, treatments, and diagnosis to apply evidence-based guidelines (e.g. InterQual) and medical policies for prior authorization and concurrent reviews. Follows the applicable regulatory guidelines (NCQA, CMS, State) and ensures timely review with clear accurate communication to members and requesting providers. Based on medical necessity and clinical best practice proactively engages with members and providers to ensure safe and efficient medical care, appropriate length of stay, and safe transitions of care. Works closely with care teams, facilities, and providers to meet the complex needs of the member. Recognizes members unique needs and refers to Care Management, Pharmacy, Appeals, or other products, services, and/or programs. Collaborates with physicians, internal staff, members, and families to assist in expediting appropriate discharge, obtain authorizations, and directs toward medically necessary care. Resolves provider, member, family/caregiver questions regarding authorizations, approved treatment plan and length of stay. Qualifications: Minimum Qualifications: Current RN (Nurse) compact license to practice in all states that are part of the compact and may be asked to have additional state licenses as needed to practice in Select Health Regions. Demonstrated experience and expertise working in clinical nursing. Minimum 1 year experience in care management/navigation or closely related field including: Utilization Management, discharge planning, managed care, health promotion, health coaching, behavioral health, or Patient Educator job role. Strong written, verbal communication and conflict resolution skills. Basic computer hardware set-up, ability to customize computer settings and use multiple monitors and capable of independent troubleshooting internet and applications. RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion. Preferred Qualifications: Bachelor’s degree in nursing (BSN) from an accredited institution (degree will be verified). Case Management Certification. Three years of experience and expertise working in clinical nursing in an ambulatory care setting, community health or home care. Experience working with third party payers. Ability to work independently and be flexible in a rapidly changing environment. Demonstrated excellent written and verbal communication skills. Experience working successfully working in a remote environment or using Advanced Microsoft Suite, including Teams (chat, whiteboard, task tracking) & Outlook. Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment. Physical Requirements: Ongoing need for employees to see and read information, documents, monitors, identify equipment and supplies, and be able to assess customer needs. Frequent interactions with colleagues and providers require employee to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately. Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use for typing, accessing needed information, etc. May be expected to sit or stand in a stationary position for an extended period of time.

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