Clinical Guide: UM Nurse (Outpatient Prior Authorization)- REMOTE

Job Description

Schedule:

This role supports our weekend operations and requires availability every Saturday and Sunday. The weekly schedule is a 5-day (8-hour) schedule, totaling 40 hours per week. Shifts are scheduled within the hours of 8:00 AM–8:00 PM ET.

A bit about this role:

As a Clinical Guide, you'll have the opportunity to make a difference in the lives of our members.  You'll be responsible for providing clinical review of cases using standard criteria to determine the medical appropriateness of inpatient and outpatient services while supporting our members through assessment, care, and conservation. You'll serve as an advocate for our members, coordinating care and ensuring they have the necessary resources and support to achieve their health goals (recovering from an illness, improving quality of life, overall well-being, etc.) Our Clinical Guide is committed to integrity and excellence and empowering members to confidently navigate the healthcare system and live healthier lives.  Our ideal Clinical Guide is caring, compassionate and solutions-oriented, and is enthusiastic about providing outstanding experience for Devoted Health’s members.

Your Responsibilities and Impact will include:

• Engage with members and understand their needs, using technology and data to better understand the member and any unspoken needs.

• Performs initial, concurrent, and discharge reviews of all cases, including using medical guidelines to determine the medical appropriateness of inpatient and outpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating and resolving complex cases or issues as required.

• Reviews current charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients).

• Alerts and collaborates with appropriate leadership concerning patients who do not meet medical appropriateness criteria.

• Obtains admission and continued stay certification or recertification.

• Communicates with an attending physician regarding patients who do not meet criteria to identify additional documentation needs or potential status change.

• Coordinates care and discharge planning. Makes arrangements for appropriate post-hospital care, including physical and behavioral medicine, transportation, equipment, home health care, etc.

• Identifies, documents, and communicates potential quality assurance or risk management issues as appropriate.

• Conduct holistic assessment to identify co-morbid conditions, ED/ hospitalization history, medications, psycho-social factors, and member values and preferences.

• Collaborate with our PCP partners.

• Develop care plans in partnership with members and their caregivers - problems, goals, interventions - continuously evaluating the member’s progress.

• Work closely with Local Service Guides to identify community-based organizations to support the members in meeting their goals.

• Collaborate with members, providers, and caregivers to ensure a positive outcome.

• Explain complicated medical terms in plain language.

• Educate members on appropriate care and settings based upon their healthcare needs.

• Support members in understanding diagnostic tests and treatments, including costs, risks, and alternatives so they can make an informed decision.

• Prepare members for their inpatient and outpatient treatments and coordinate post-treatment care.

• Support and coach members to improve management of their chronic conditions, including medication adherence and compliance.

Required skills and experience:

• Ability to work in a startup, fast paced environment. 

• An unrestricted RN license.

• A minimum of 4 years of RN experience.

• A minimum of 3 years’ experience doing utilization management at a health plan.

• The ability to comfortably multi- task: you’ll be listening, talking, and typing all at the same time.

• Team player mentality with a can-do attitude.

• Understanding of CMS guidelines and MA requirements.
   

Desired skills and experience:

• A desire to make a change in the health care experience: you love to serve and