Remote Aetna Utilization Review Jobs in Iowa (NOW HIRING)

We are seeking an RN Utilization Management Specialist to join our team at UnityPoint Health! This position serves a key role in coordinating the organization’s interdisciplinary effort to assess and promote appropriate utilization of health care resources, provision of high-quality health care, optimal clinical outcomes, and patient and provider satisfaction. The RN UM Specialist will work to track and minimize the inappropriate use of such resources, provides the Utilization Management function for patients admitted to UPH, and facilitate effective utilization of resources through ongoing interactions with physicians, third party payers and regulatory agencies.

Hours: Weekend-days, Saturday & Sunday, 7am-3:30pm

Location: Remote - applicants must reside within the UnityPoint Health footprint of Iowa, Illinois, or Wisconsin 

At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.  

Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. Here are just a few:   

• Expect paid time off, parental leave, 401K matching and an employee recognition program.   

• Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.  

• Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.   

With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together.  

And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. 

Find a fulfilling career and make a difference with UnityPoint Health.

• Performs utilization management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources. 
• Maximizes positive financial outcomes for patients and hospital by conducting timely initial and ongoing concurrent chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care.   
• Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making. 
• Requests secondary reviews with physician advisors as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status. 
• Assesses patient status, including reviewing outpatient surgical and observation admissions for the appropriate level of care, and continuously monitors length of stay for appropriate and timely medical management.     
• Applies accepted potentially avoidable day logic to reviews for accurate and timely data collection.    
• Proactively monitors insurance approval status in partnership with the UM Administrative Coordinator.  
• Provides education to staff and physicians regarding medical necessity, levels of care and appropriate utilization of resources as needed.  
• Pursues denials at the affiliate level in a timely manner to secure payment of services.
• Serves as a resource to internal and external staff, providers, payers, and patients on issues related to utilization management  
• Maintains current knowledge of Utilization Review Methodology, software, criteria, and regulations governing various payment systems. 
• Maintains current knowledge of the UPH Utilization Management Plan. 
• Maintains current knowledge of CMS rules (e.g., Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement.  
• Coordinates and monitors appeals with internal and external physician advisors for Second Level Review as needed. 
• Provides education to patients and families regarding the role of the Utilization Management Specialist and provides clarification when needed on level of care and their payer source regulatory requirements – as needed.  

Education:

• Required: Associates Degree or Diploma (RN) in Nursing 
• Preferred: Bachelor’s Degree or higher preferred in nursing, business, or related field 

Experience: 

• Required: 2 years of nursing experience
• Preferred: 5+ years of nursing experience
• Preferred: Experience in Utilization Management, case management, denials, or managed care
• Preferred: Management experience a plus

Licensing/Certifications: 

• Required: Registered Nurse – Licensed and registered in the appropriate state(s) 
• Valid driver’s license when driving any vehicle for work-related reasons