Intus Care is seeking a dynamic and experienced Population Health Nurse with utilization management experience.  This position this position will support the Interdisciplinary Team and other stakeholders through robust data analysis to promote care coordination, prevent hospitalizations, and minimize unnecessary and/or unwanted participant care. 

What We Do:

In This Role You Will:

• Utilization Management
  • Assure rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are:
    • Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions.
    • In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles.
  • Actively participate in and/or manage various aspects of the utilization management process, including:
    • Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization.
    • Concurrent review of all subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care.
    • Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions.
  • Coordinate Claim Disputes - In cases of claim rejection, the Intus Care Utilization Management Nurse will lead the provider dispute process. Responsibilities Include:
    • Comprehensive review of provider network disputes.
    • Collaboration with the PACE program finance and claims adjudication team to coordinate clinical review to support disputed claims as needed.
    • Collaboration with the PACE Program's Medical Director to review and respond to disputes, ensuring issuance of a written determination consistent with the PACE program policies.
• Population Health Management
  • Design, implementation and management of population-based care coordination activities.
  • Monitor patient outcomes and analyze data to measure the effectiveness of clinical initiatives.
  • Using the Intus Care application, EMR, and other data sources, assesses the health and care needs of PACE participant populations and subpopulations:
    • Identifies PACE participant subpopulations at risk for decline and/or hospitalization due to comorbid conditions and utilization patterns.
    • Identifies groups and subpopulations that will benefit most from coordinated health care promotion activities.
    • Coordinates and communicates with Medical Director and other stakeholders to develop and implement strategies to address unique care needs of subpopulations to promote health and well being.
    • Follows the progress of population management strategies and reports progress to Medical Director and other stakeholders and facilitate continued strategy iterations. 
  • Using the Intus Care application, EMR, and other data sources, identifies high risk participants with imminent risk for decline and/or hospitalization:
    • Presents participant specific conditions and scenarios to IDT and clinic care teams to focus team resources daily for participant follow up to address and resolve identified risks.
    • Follows the progress of the participant to evaluate and communicate the effectiveness of the implemented intervention/treatment plan. 
    • Identifies and communicates blockers to participant access to care
  • Facilitates “shared goal model” within and across settings to achieve coordinated high-quality care that is participant and care giver centered. 

Qualifications:

• 3 to 5 years of utilization management experience.
• Current RN license
• Proven experience working in risk based integrated models of care.
• Ability to use data to drive decisions and collaboration with internal and external stakeholders.
• Strong critical thinking skills and strong, autonomous self-management
• Comfortable with rapid cycle improvement and thrives in fast paced performance improvement environments. 
• Ability and willingness to identify and initiate process improvement strategies to implement and iterate on system changes. 
• Strong strategic thinking, problem solving, and decision-making skills.
• Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies

What We Offer:

• A chance to be a part of a trailblazing team in healthcare technology.
• Competitive salary package.
• Comprehensive benefits including health, dental, and vision insurance.
• A collaborative, inclusive, and dynamic work environment.
• Opportunities for professional growth and development.

Company Core Values:

• Take Ownership For Your Responsibilities and Outcomes
• Think With Data First
• Be Passionate About Impact
• Take Strides Toward Growth and Innovation
• Be Supportive Of Each Other