• Utilization Management Nurse

    Location US-IA-Des Moines
    Job ID
    Clinical/Provider Support
    Requires Non-Compete?
  • Job Summary

    Our Utilization Management Nurse will provide service and support to members and health care providers, including pre-service reviews, out of network referrals and support for Wellmark’s Health Plan of Iowa. This individual will utilize clinical knowledge and expertise to interpret and appropriately apply medical policy, medical criteria (InterQual), and benefit information, and provide consultation and responses to utilization management requests. Additionally, this individual may complete clinical reviews and apply utilization review criteria for patient admissions and various levels of care, continued stay reviews, and/or discharge planning.


    Are you a dedicated, compassionate health care professional with the ability to adapt to change, anticipate needs, and pay excellent attention to detail? Are you organized, inquisitive, and would you thrive in a collaborative setting, while exhibiting independent and critical thinking where resourcefulness is key? Are you motivated and inspired by the opportunity to utilize your clinical expertise in a fast-paced production environment? If you said yes, consider applying today!


    This position is located in our Des Moines, IA office.

    Minimum Qualifications Required (all must be met to be considered)

    • Completion of an accredited registered nursing program or licensed practical nursing program.
    • Active and unrestricted RN or LPN license in Iowa or South Dakota; individual must be licensed in the state in which they reside.
    • 3+ years of clinical experience (e.g. critical care, acute care, outpatient) with a minimum of 3 years of full time equivalent of direct clinical care to the consumer. 
    • Ability to establish relationships and effectively engage with members and providers through telephonic communication to obtain necessary information and facilitate care in multiple settings.
    • Demonstrated experience applying analytic and critical thinking skills with ability to make independent decisions.
    • Ability to influence and negotiate in order to effectively manage patient care and health care costs.
    • Experience with computer software applications – e.g. Microsoft Suite, electronic charting, documentation systems, etc.
    • Knowledge of the diagnosis and procedure coding systems – e.g. ICD-9, HCPC, CPT.
    • Strong written and verbal communication skills with the ability to express complex concepts clearly and concisely. 
    • Ability to work in a fast-paced environment where production and/or quality goals are measured. Demonstrated commitment to timeliness, follow up, effective prioritization, accuracy, and attention to detail.


    Hiring Specifications Preferred

    • Bachelor's degree in Nursing.
    • Active and unrestricted RN license in Iowa or South Dakota.
    • Certified Professional Coder (CPC) or UM Certification.
    • Experience in utilization management in a clinical or health insurance setting with a diverse medical background. Demonstrated experience interpreting health care benefits.
    • Previous experience working independently and managing an assigned caseload in a metrics-based environment.
    • Knowledge of regulatory standards and regulations – e.g., URAC, NCQA, HIPAA, PHI, confidentiality.



    Job Accountabilities

    a. Provide members and health care providers with appropriate and timely prior approval, pre-service and continued stay reviews determinations and Wellmark Health Plan of Iowa WHPI out of network utilization management service and support prior to providing hospital and/or clinical services by obtaining medical information necessary to make a clinical determination based on appropriate medical policy or criteria. Interact with Wellmark Medical Director, physician consultants and/ or vendors as appropriate.

    b. Provide utilization management service, prior approval pre-service review determinations and or continued stay reviews and support to members while located in an acute health care facility, skilled or other level of care facility, or home health care admissions. Process utilization management requests by utilizing clinical knowledge and expertise in interpreting medical policy, medical criteria InterQual, and benefit information for internal/external customers within the timeframes described in the requirements. Interact with Wellmark Medical Director, as appropriate for levels of care that do not meet medical criteria.

    c. Work with health care provider staff in a courteous and professional manner in gathering medical information to ensure accurate diagnosis codes for documentation and reporting purposes. Influence, collaborate and negotiate with providers in an open, direct and supportive manner to resolve conflicts, utilization review issues and alternative treatment setting options.

    d. Responsible for the utilization review process, monitoring patients progress, screening and assessing for discharge and transition of care planning needs. Identify key issues and barriers to discharge ensure development and facilitation of discharge plan.

    e. Work in collaboration with other health care management teams and stakeholders, both internal and external to Wellmark, to provide optimal service and meet the needs of the member, coordinate care and make appropriate referrals to other Health and Care Management programs. Meet both quality assurance and production metrics as established for the utilization management unit.

    f. Document events accurately, consistently and timely within CCMS by following the standard work guidelines and policies to support internal and external processes, including documentation of potential avoidable days/ admission when medical necessity criteria are not met. Communicate approval and denial notifications and decisions to members and/or providers using both verbal and written communication. Log denials as appropriate.

    g. Comply with regulatory standards, accreditation standards and internal guidelines remains current and consistent with the standards pertinent to Utilization Management Services.

    h. Other duties as assigned.


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