Registered Nurse (RN) from Epitec, Inc.

Utilization Management Medicare Advantage Post-Acute Care RN

***Training will be onsite for first 2 weeks, then fully remote.

Summary:

• Use established medical policy and guidelines to perform prospective, concurrent, and retrospective medical necessity review of post-acute care services to ensure medical necessity for appropriate setting, appropriate length of stay, including appeal requests initiated by providers, facilities and members.
• Will coordinate care through the health care continuum including member outreach.
• Provides support and alternative care support for member not appropriate for post-acute care service as well formulate discharge readiness for members transitioning from a post-acute care setting to a lower level of care.

Required Experience:

• Bachelor’s degree in nursing, allied health, business, or related field preferred.
• Two (2) to four (4) years of clinical experience which may include post-acute care, home care, acute patient care, discharge planning, case management, and utilization review, and caring for aging population in the home or post-acute care setting, etc.
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes.
• One (1) year health insurance plan experience or managed care environment preferred.
• Registered Nurse with current unrestricted Michigan Registered Nurse license required.

Preferred:

• Understanding Medicare Requirements for skilled vs non-skilled services in post-acute care and home setting.
• Certification in Case Management.
• Experience with management of patients with compromised airways requiring skilled services.
• Experience with goals planning and intervention for patients recovering after unplanned or prolonged hospital admission including but not limited to stroke, hip and femur fractures with surgical intervention after a fall, sepsis, ventilator dependency, sever change in functional ability