Utilization Management Nurse

COMPANY OVERVIEW 

Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the health care equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs and a dedicated care team. For more information on Zing Health, visit www.myzinghealth.com. 

SUMMARY DESCRIPTION: 

The Utilization Management Nurse will be responsible for reviewing prior authorizations and concurrent review of cases that come into our Utilization Management Department. 

ESSENTIAL FUNCTIONS: 

Fundamental Components includes but are not limited to: 

• Performs medical necessity review of cases 
• Works with discharge planners, etc to ensure safe discharge plans for members 
• Participates in assessment activities to develop individualized plans of care in coordination with patient, family, and providers. 
• Ability to organize information to assist the Medical Director in making determinations 
• Provides member notification of status of authorization per CMS guidelines 
• Serves as a member advocate and resource and provides critical information and recommendations to the rest of the care team. 
• Documents in our Utilization Management business application according to defined standards, processes, and workflows 
• Works collaboratively with physicians, specialists, and other care providers to ensure member compliance and adherence to medical plan of care. 
• Follows standard protocols, processes, and policies. 
• Interacts with Medical Directors, Pharmacists, Social Workers, Behavioral Health Clinicians, and Other Impact Team Members on cases 
• Makes referrals to outside sources. 
• Documents and tracks clinical reviews, referrals, and findings 
• Performs other duties, projects and actions as assigned. 

•  Registered Nurse (RN), with 3 years’ experience in Utilization Management 
• Current, valid, unrestricted license  
• 3 years of managed care experience or other commensurate experience 
• Demonstrates strong clinical knowledge, ability to use critical thinking skills and has the capacity for continued learning. 
• Knowledge of Medicare benefits and systems to process medical necessity reviews 
• Ability to demonstrate knowledge of and apply those to the job function and responsibilities. 
• Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action. 
• Excellent verbal and written communication skills  
• PC proficiency to include Outlook, Word, Excel, , database experience and Web based applications. 
• Personal management skills — Plan and manage multiple assignments and tasks, set priorities and adapt to changing conditions and work assignments. Teamwork — ability to work well with one or more groups. 
• Interpersonal effectiveness — Relate to co-workers and build relationships with others in the organization. 

Preferred Qualifications

•  5-7 years Utilization Management experience with a Managed Care Organization (MCO)