Using a collaborative process, the Care Management (CM) Utilization Management Nurse (RN) will review, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, and cost-effective outcomes. He/she helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner while maintaining quality of care. The CM Utilization Management Nurse (RN) is responsible for evaluating the medical appropriateness, quality, and cost effectiveness of proposed services in accordance with established criteria. This review activity may be conducted prospectively, concurrently, or retrospectively and in collaboration with patients, practitioners, and other professionals.
1.Graduation from an NLN accredited school of Nursing. Bachelor’s degree is preferred.2.Valid current license to practice in the State of Wisconsin as a Registered Nurse is required.3. Minimum of one (1) year experience in: Utilization Review, Insurance/Managed Care, Home Health and/or diversified clinical experience, two (2) years preferred. 4.Knowledge of utilization principles, methods, and techniques with experience in primary and/or acute care management. Ability to follow established criteria, policies, and procedures utilized in medical reviews.5.Ability to keep abreast of legal and regulatory changes affecting the delivery of care.6.Excellent oral and written communication skills required. Ability to communicate effectively in person, in groups, and on the telephone. 7.Ability to be culturally sensitive and to work with a diverse patient population.8.Knowledge of and ability to use computer based applications such as MS Office, (word processing, email, calendar). Knowledge of and/or ability to learn and effectively use electronic medical and insurance record systems. Experience with EPIC systems is desirable but not required. 9.Ability to maintain patient and organizational confidentiality required. Knowledge of or ability to learn HIPAA requirements.
About Group Health Cooperative of South Central Wisconsin (GHC-SCW)
Group Health Cooperative of South Central Wisconsin (GHC-SCW) is a not-for-profit managed health care organization that provides the entire spectrum of health care services, including insurance, Primary Care and Specialty Care. . GHC-SCW has a history of firsts including electronic medical records (through Epic Systems), smart phone capabilities, and Complementary Medicine.GHC is committed to con...tinuously improving the quality and safety of health care and the quality of services provided to GHC-SCW members. This commitment is reflected in GHC-SCW’s “Excellent” accreditation status, the highest level of accreditation granted by the National Committee for Quality Assurance (NCAQ), and in GHC-SCW continued regional and national recognition as a top performing health plan for effectiveness of care measures.