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Utilization Review Nurse

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06/25/2015+-Utilization Review Nurse

 This position is responsible for ensuring medically appropriate and necessary, high quality, cost effective care throughout the UR process within the THP Network. This individual communicates with network partner, contractors and related entities. This position is responsible for both pre-authorizations for out/in patient utilization management, and UR concurrent with member treatment in a variety of settings, the ideal candidate should be prepared to provide UR services in all but not limited to; behavioral health hospital, skilled nursing facility, ambulatory care and/or home health environments.Collaborates with other members of the health care team to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. In conjunction with the patient, family and healthcare team, creates a discharge plan appropriate to the patients’ needs and resources.

This role reports directly to the Director of Utilization Management. The ideal candidate for this position should:

-Excel in a fast paced environment
-Have a strong and consistent phone presence
-Strong ability for attention to detail
-Have proficient knowledge of Microsoft Office tools
-Have proficient knowledge of Utilization Review

Trusted Health Plan (THP) has been awarded the opportunity to serve the people of Washington D.C. by helping our neighbors obtain the services they need to lead a long and healthy life.

Trusted Health Plan (THP) is different. We are a D.C. Organization, staffed by many D.C. employees committed to serving our neighbors and community.

We are headquartered east of the river to ensure convenient access to members living in Wards 7 & 8. We are local and are here to provide outstanding support to our membership. Trusted Health Plan offers a fast paced unique work environment, a results driven team, and an excellent benefits package.

Benefits include; medical, vision, dental, life insurance, STD/LTD, retirement plan with company match, company paid VIDA fitness gym membership.

Required experience:
Registered Nurse License in DC

Degree in Health/Nursing field (Preferred)

Required experience:

  • Healthcare Case Management/ Discharge planning/ Utilization Management: 2 years
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