RN - LEAD CARE COORDINATOR - Utilization Review

Employment Type : Full time

Full time

Shift : Description :

Description :

This position is located at the Westmont office

Join our small but mighty team to guide and manage Utilization Review and Management for the Loyola Physician Partners LPP) Health Plan, a delegated entity for BCBS HMO Medicare and Commercial coverage.

Experience with mcg or Interqual and Epic EMR are highly desired as well as experience with inpatient UR and / or outpatient referral authorizations.

Great opportunity for a Lead Care Coordinator to work in an organization that focuses on treating the whole person, physically, emotionally and spiritually.

We are seeking a Lead Care Coordinator who is dedicated to providing exceptional care to those we serve at Loyola Medicine.

In return, we provide a supportive atmosphere where you can grow your career and make a lasting impact.

Under the direction of the Director / Manager oversees the daily caseloads of the UR / UM teams. This includes utilization review of inpatient medical and behavioral health services to assess appropriateness of level of care and collaborate with case managers to facilitate transition to the most appropriate level of care.

Evaluates medical necessity of preauthorization requests utilizing defined criteria. Collects, analyzes and communicates relevant utilization management information to insurers and third party payers.

Position Responsibilities :

Under the direction of the Director / Manager develops, implements and monitors administrative and clinical processes to ensure staff activities are focused on achieving the LPP program goals to improve quality of care, mitigate cost trends through supporting optimization of utilization review for medical necessity using established care guidelines and ensuring benefits are covered by the health plan.

Coordinates assignment of daily work, ensures work completed within required timeframes and examines work product to ensure it meets department clinical and process guidelines.

Provides feedback to staff on performance including identifying performance improvement opportunities and working collaboratively with staff to develop and implement remediation plans.

We offer our employees :

• Benefits from Day One
• Competitive compensation
• Career Development
• Tuition Reimbursement
• On Site Fitness Center
• Educational Stipend
• Referral rewards

Our Promise to You :

Joining Loyola Medicine is being a part of an organization that treats the human spirit in our patients and in our colleagues.

We are a part of a community which believes in giving back to those we serve.

We seek colleagues with :

Education :

Required : Bachelors Degree

Preferred : Masters Degree OR equivalent training acquired via work experience or education

Specify Degree(s) : BSN, Physical or Occupational Therapy

Experience :

Required : 3-5 years of previous job-related experience

Preferred : 6-10 years of previous job-related experience

Details : UM / UR experience with an insurance company, IPA or MCO. Leadership experience is preferred.

Licensure / Certifications :

Required : Current Registered Nurse License State of Illinois

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do.

Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve.

Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.