Utilization Review Rn Jobs in Pittsburgh, PA (NOW HIRING)

This job has responsibility for creating, implementing, and evaluating care plans for patients and their families/caregivers across the health continuum. Incumbents will utilize nationally recognized standards of practice for case management by collaborating with providers, clinical teams, health plans, and external partners while advocating for patients and caregivers in order to align goals and plans. Incumbents will serve as professional role models, utilizing their expertise in care management to promote a collaborative professional environment that optimizes outcomes, engages patients/caregivers in their healthcare, and supports effective resource utilization. Serves as key team members in the management of readmissions, length of stay, ED utilization, and patient/family satisfaction.

• Contributes to or completes comprehensive assessment of patients and their families/caregivers, inclusive of clinical/physical needs, social determinants of health, and economic barriers impacting their ability to manage their health. (20%)
• Effectively identifies barriers and analyzes situations for assigned patient population, including risk for admission/readmission, external resources, and patient/family capacity in order to determine safe plans for transition and care coordination. (20%)
• Coordinates the clinical care with the patient, family, provider(s), and members of the interdisciplinary team. (25%)
• Advocates for patients and families through effectively communicating with providers, interdisciplinary team members, payers, and post-acute partners to assure effective outcomes and care. (15%)
• Leverage understanding of industry standards to provide applicable education to patients, families, providers, and interdisciplinary team partners including but not limited to: appropriateness of care, documentation requirements, utilization review principles and criteria, insurance benefits and limitations, transition planning requirements, length of stay, and resource utilization. (10%)
• Actively seeks professional development opportunities through professional certification, mentoring/precepting, and/or participation on department/hospital/system committees. (5%)
• Adheres to the policies, procedures, rules, regulations, and requirements of hospitals and other clinical settings. (5%)

Minimum Bachelor’s Degree in Nursing -OR- Bachelor’s Degree and Nursing Diploma -OR- 6 years of relevant experience in lieu of a degree 3 years in a clinical nursing role Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Critical thinking and problem solving Flexibility and adaptability to change Strong communication and collaboration skills with ability to tailor style according to target audience (providers, peers, clinical team members, patients, families) Preferred Nationally recognized Case Management Certification Transition planning and understanding of community and facility resources Knowledge of motivational interviewing techniques BSN LICENSES or CERTIFICATIONS Required None Preferred ACM Certification (Accredited Case Manager) - American Case Management Association - American Case Management Association Case Management - American Board of Occupational Health Nurses (ABOHN) and Certified Case Manager (CCM) Commission for Case Manager Certification (CCMC)

CPR – American Heart Association Act 34 Criminal Background Clearance Certificate Act 33 Child Abuse Clearance Certificate Act 73 FBI Fingerprinting Criminal Background Clearance Certificate Professional Certification within 5 years of start date. Incumbents in role as of 12/1/2022 have until 12/31/2026 to obtain Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services.