Utilization Mangement Nurse-Temporary

IntusCare is seeking an experienced Registered Nurse with experience in utilization management to join our team to cover a parental leave. In this role, you’ll support Interdisciplinary Teams and key stakeholders by leveraging data-driven insights to enhance care coordination, reduce hospitalizations and ensure participants receive the right care, at the right time, for their individual needs and goals.

You’ll also play a vital role in partnering with IntusCare’s PACE customers to improve communication across provider networks, Medical Directors, IDTs and finance teams. Your work will help streamline service authorization processes, ensure high-quality care delivery, and promote accurate, timely documentation to support appropriate claim payments and care outcomes.

What We Do

Intus Care is a healthcare analytics platform that synthesizes healthcare data to identify risks, visualize trends, and optimize care for PACE programs. Intus Care empowers care providers to mitigate high risk events and equips executives with the tools to make informed decisions based on comprehensive clinical and operational data. Our mission is to catalyze data driven change to achieve high-value, multi-disciplinary care for older adults. In addition, Intus Care offers a broad range of technical assistance and consulting services to support new PACE programs under development and existing programs that are growing and evolving to meet the needs of their communities.

Responsibilities

• Assure rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are:

  • Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions.

  • In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles.

• Actively participate in and/or manage various aspects of the utilization management process, including:

  • Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization.

  • Concurrent review of all subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care.

  • Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions.

• Coordinate Claim Disputes - In cases of claim rejection, the Intus Care Utilization Management Nurse will lead the provider dispute process. Responsibilities Include:

  • Comprehensive review of provider network disputes.

  • Collaboration with the PACE program finance and claims adjudication team to coordinate clinical review to support disputed claims as needed.

  • Collaboration with the PACE Program's Medical Director to review and respond to disputes, ensuring issuance of a written determination consistent with the PACE program policies.

• Mentorship of UM team

Qualifications

• 3 to 5 years of utilization management experience. 

• Current RN license

• Proven experience working in risk based integrated models of care.

• Ability to use data to drive decisions and collaboration with internal and external stakeholders.

• Strong critical thinking skills and strong, autonomous self-management 

• Comfortable with rapid cycle improvement and thrives in fast paced performance improvement environments.  

• Ability and willingness to identify and initiate process improvement strategies to implement and iterate on system changes.  

• Strong strategic thinking, problem solving, and decision-making skills.

• Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies 

What We Offer

• A chance to be a part of a trailblazing team in healthcare technology.

• Competitive salary package.

• Comprehensive benefits including health, dental, and vision insurance.

• A collaborative, inclusive, and dynamic work environment.

• Opportunities for professional growth and development.

Company Core Values

• Take Ownership For Your Responsibilities and Outcomes

• Think With