Employment Opportunity

Aveta Health Solutions has an immediate opening for an Ambulatory/Utilization Management, RN in our Kansas City office in Missouri. To apply for this opportunity, please submit your resume at HR@nammcal.com

RESPONSIBILITIES:
Reviews all requests for specialty care, elective surgeries, treatment plans and diagnostic studies in accordance with Humana health plan and CMS timelines.
Utilizes health plan, CMS, Milliman and Hayes as sources for documenting appropriateness and standard of care. Seeks consultation from IPA Medical Director when request for services does not meet health plan, CMS, Milliman or Hayes recommendations.
Seeks to obtain a complete data set about the treatment plan and patient progress. This can include calling the attending physician, discussing therapy with the physical therapist and/or consultation with the primary nurse.
Tracks and trends over-utilization of procedures, resources and benefits by provider.
Documents access to care issues/unable to provide services in UM information system if capitated provider is unable to provide requested service.
Works closely with the Appeal and Denial Unit by providing requested information and completing denial paperwork within timeframes.
Channel referrals to contracted providers.
Provides case management services for members who require elective surgery.
Interfaces effectively with IPA Medical Directors, contracted physicians, vendors, and other contracted providers as needed.
Completes an average of 60 referrals/day

SKILLS REQUIRED:
RN license - licensed in Missouri and Kansas
RN with 2 years of acute care experience (preferred)
2 year of previous UM experience (preferred)

BENEFITS:
Competitive benefits include but are not limited to: Medical, Dental, Vision, Short and Long Term Disability, Life Insurance, Educational Reimbursement, Paid Holidays, 401K, and more!