Denials Management Nurse Jobs (NOW HIRING)

Medical Associates is looking for a Utilization Management Nurse to join our Health Care Services team! Schedule: Primary schedule will be Monday through Friday 8:00am to 5:00pm, 40 hours/week with flexibility. After training, there is opportunity for work from home if desired.

Location: Training is in-person at Medical Associates Health Plans, 1605 Associates Drive, Dubuque, IA 52002

Benefits Package Includes:

• Single or Family Health Insurance with discounted premium rates for wellness program participation.
• 401k with immediate matching (50% on the dollar up to 7% of pay + additional annual Profit Sharing)
• Flexible Paid Time Off Program (24 days off/year)
• Medical and Dependent Care Flex Spending Accounts
• Life insurance, Long Term Disability Coverage, Short Term Disability Coverage, Dental Insurance, etc.

What You Will Be Doing:

• Review requests from providers or members for approval of procedures, medications, durable medical and/or services prior to delivery of the service.
• Utilize established screening criteria to ensure patients get the correct treatment from the resources that are available at the most cost-effective level to meet their needs.
• Facilitate options and services for meeting individuals' health needs with the goal of decreasing fragmentation, duplication of care and enhancing quality, cost‑effective clinical outcomes.
• Review of hospital and skilled admissions to justify continued care is medically necessary per Health Plan established guidelines.

Essential Functions & Responsibilities:

1. Conduct reviews inclusive of physician referrals, medication reviews, admissions, utilization review updates, investigating alternatives to hospitalization such as home health care and durable medical equipment, utilizing the assessment process by obtaining pertinent patient history and accurate vital data, anticipating patient and family needs, working with the Health Choice Claims and Membership Services to determine benefit eligibility, facilitating crisis intervention, sharing information with co‑workers and documenting accurately. Utilize established screening criteria to determine medical necessity of requested authorizations. Refer patients to case management nurse or health coach as appropriate.
2. Facilitate out‑of‑plan referrals, out‑of‑area urgent and emergent care for enrollees and provider offices and provide necessary information to Medical Director on specified referrals. Communicate decision to enrollees, providers, and facilities per established policies.
3. Work collaboratively with internal and external staff, in determining extent of benefits and coverage for services being coordinated. Document authorizations, denials, cost savings and other outcome measurements.
4. Act as a resource for the enrollee, provider offices, and other MAHP departments. Perform retrospective review to determine coverage of hospitalizations, and outpatient services. Communicate with enrollees regarding the use of managed care systems and participate in answering enrollees and providers inquiries.
5. Assist in preparations for external review/regulatory agencies.
6. Complete all other assigned projects and duties.

Knowledge, Skills and Abilities: Experience - Three years to five years of similar or related experience. Education - Valid RN nursing license is required.

Physical Aspects: Stooping - Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles. Reaching - Extending hand(s) and arm(s) in any direction. Standing - Particularly for sustained periods of time. Walking - Moving about on foot to accomplish tasks, particularly for long distances. Lifting - Raising objects from a lower to a higher position or moving objects horizontally from position-to-position. This factor is important if it occurs to a considerable degree and requires the substantial use of the upper extremities and back muscles. Fingering - Picking, pinching, typing or otherwise working, primarily with fingers rather than with the whole hand or arm as in handling. Grasping - Applying pressure to an object with the fingers and palm. Talking - Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly or quickly. Hearing - Perceiving the nature of sound with or without correction. Ability to receive detailed information through oral communication and to make fine discriminations in sound, such as when making fine adjustments on machined parts. Vision - 20 / 40 or better in the best eye with or without correction. Repetitive Motions - Substantial movements (motions) of the wrists, hands and/or fingers. Sedentary Work - Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Environmental Conditions: None - The worker is not substantially exposed to adverse environmental conditions (such as in typical office or administrative work).

Medical Associates Clinic & Health Plans is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, pregnancy, age, national origin, marital status, parental status, disability, veteran status, or other distinguishing characteristics of diversity and inclusion, or any other protected status.