Signature Healthcare Home Office

Lexington, KY, US,

APPLY NOW

Description:

For additional information, please contact:
Hillary Bayens, SR Director of Talent Acquisition
hbayens@signaturehealthcarellc.com
#LI-HB1

This opportunity is remote will possible travel to a Signature facility.:

Do you have Case Management experience? Apply Now!:

Signature HealthCARE is a family-based healthcare company that offers integrated services in 8 states across the continuum of care: skilled nursing, rehabilitation, assisted living, memory care, cognitive care, and telemedicine.

A growing number of our centers are earning quality assurance accreditation and pioneering person – directed care. Many of our skilled nursing facilities have achieved a 4 or 5-star overall rating from the Centers for Medicare Medicaid Services. Additionally, we have been awarded as a certified Great Place to Work for three years in a row and Modern Healthcare’s “Best Places to Work!”

Signature HealthCARE is an industry leader in post-acute, long term care and rehabilitation services. We operate over 75 locations across 8 states employing over 8,500 Stakeholders (our thoughtful and loving employees).

Our Sacred Six Values of Compassion, Teamwork, Respect, Integrity, Patience and Positivity make this an incredible place to serve and make a difference in the lives of our patients, residents, Stakeholders and communities!

At Signature HealthCARE, our team members are permitted – no, encouraged – to employ their talents and abilities to solve problems. Our culture is built on three distinct pillars: Learning, Spirituality and Intra-preneurship. But this isn’t just hollow corporate sloganeering. Each pillar has its own staff and initiatives, ensuring that our unique culture permeates the entire organization.

Oh, by the way, we’re an elder care company. Our mission? To radically change the landscape of long-term care forever.

The utilization review (UR) nurse ensures that authorization requests, provider and member clinical inquiries are processed timely and handled appropriately within member’s plan benefits coverage and established clinical guidelines utilized for appropriate clinical decision-making. The UR nurse functions collaboratively with individuals within the Utilization Management team, and specifically with the inpatient review nurses, Case Managers, and Medical Directors to ensure timely determination of inpatient and outpatient medical services authorization requests.

The UR nurse’s role include the following responsibilities:

• Perform review of requests for services/procedures including, but not limited to, elective surgery (inpatient and outpatient), skilled nursing facility and therapy services, durable medical equipment (DME) and supplies that require medical necessity review and/or benefit interpretation

• Use of established medical criteria to approve services based on information obtained from attending physician and/or other providers

• Ensure full collection of clinical information prior to rendering a decision

• Ensure timely determination of requests according to established processing timeframes

• Contact providers where additional information is necessary to make a decision

• Consult with Medical Director as appropriate for all requests that do not meet criteria and inform providers of the Medical Director’s decisions

• Act as a member/family advocate in coordinating and accessing medical necessity health care services within the benefit plan

• Respond to member/member’s authorized representative questions regarding the disposition of a request and/or the decision

• Manage workload needs on a concurrent basis, including authorization queues and fax queues in the UM department to concurrently prioritize self-assignment for greatest impact on department function

• Support onboarding program for UM staff by acting as primary mentor for review nurses

• In conjunction with medical leadership, act as resource for criteria and benefit interpretation including the correct and consistent application of the Milliman Care Guidelines (MCG) criteria on the appropriate topics, consistent application of procedural practices established.

• Complete authorization process in UM data management system for approved authorizations and contact providers with decision and corporate authorization number

• Create and fax/mail determination letters to members/providers as required and within established timeframes

• Receive and process clinical updates for continuation of services

The ideal UR nurse candidate will also possess the following knowledge, skills and abilities:

• Current license (without restriction) to practice as a Registered Nurse (RN) in the designated State is required

• At least one year experience in UM/UR and managed care experience is preferred

• Knowledge of medical/surgical terminology and Medicare managed care authorization processes

Signature HealthCARE is an Equal Opportunity-Affirmative Action Employer – Minority / Female / Disability / Veteran and other protected categories.: