Utilization Management RN

Imagine360 is seeking a Utilization Management, RN to join the team! The RN Utilization Management Nurse is responsible for providing utilization review / notifications and education for individuals under the group health plans administered by imagine360 by utilizing nursing education, clinical, and professional experience. The Registered Nurse will practice within the scope of practice while performing assessments, coordination, planning, monitoring and evaluation.

Position Location :   100% remote

Responsibilities include but are not limited to :

• Perform all tasks in accordance with Department of Labor, HIPAA, ERISA and Care 360 department Policy and Procedures.
• Complete HIPAA and URAC training annually.
• Identify , collect, process and manage data to complete reviews for Medical Necessity per imagine 360 approved clinical guidelines.
• Accurate utilization and documentation in appropriate software including time slips in CaseTrakker to complete and document the review process per Care 360 Policy and Procedure.
• Provide oversight to non-clinical staff members regarding interpretation of clinical data.
• Consult with Care 360 Physician Advisor or peer reviewer per policy and procedures.
• Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Care 360 Services.
• Communicates professionally and effectively as needed with members, physicians, other healthcare professionals, peers, Supervisor of UM to complete the utilization process per Care 360 Policy and Procedures.
• Utilize clinical knowledge, expertise and imagine 360 approved educational resources to provide verbal and / or written educational resources to members regarding diagnosis, procedures and / or treatment.
• Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite.
• Participate in the Quality Management program of the organization by completing the Quality Assurance review process and other procedures per policy and procedure.
• Work regular scheduled hours and be available for additional coverage outside of normal working hours as needed .
• Evaluating clinical data.
• Assessment and evaluation of the acquired clinical data to assess for appropriateness of treatment plan based upon imagine 360 clinical guidelines.
• Coordination of treatment plans, interventions and outcomes measurement.
• Rationale for the effects of medication and treatments.
• Provide patient education and educational resources.
• Accurately report :

Administration of medication and treatments

Required Experience / Education :

Skills and Abilities :

License and Certifications :

What can Imagine360 offer you?

Want to see our latest job opportunities? Follow us on  LinkedIn

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise . Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits- none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 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, or veteran status.