Utilization Management RN

Location: Bloomfield Hills, MI

Department: Utilization Management

Type: Full Time

Min. Experience: Experienced

THE COMPANY

Integra Partners is a leading, tech-enabled, healthcare benefit management company focused on community-based care. Integra has a core competency in Durable Medical Equipment (DME), Orthotics and Prosthetics (O&P), and works with providers and health plans to facilitate care for hundreds of thousands of patients each year.  We have experienced rapid growth with no slowdown in sight.

Our leadership team is amazing and focused on what really matters to our business - every employee, every experience, and every customer. With the right people, success is unbounded. This is a truly unique opportunity to take a position with a great company, surrounded by an awesome team.

In 2015, Integra’s management and Tufts Health Plan of Massachusetts acquired the business. Tufts Health Plan is one of the country’s leading, 5-star, private health plans providing healthcare to individuals and employer groups. Integra now operates as a separate financial investment and subsidiary of Tufts Health Plan with a separate board of directors and governance structure. Integra is an innovative and exciting company, with an entrepreneurial culture focused on teamwork and everyday excellence.

SCOPE AND RESPONSIBILITY

Integra’s benefit management division, DMEnsion, is looking for an RN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This individual will play a key role in collaborating with our Medical Director to perform benefit and medical necessity reviews and appeals within an NCQA-compliant UM program.

KEY RESPONSIBILITIES AND ESSENTIAL FUNCTIONS

  • Perform pre-service and post service UM authorization reviews utilizing federal and state mandates, plan benefit language and NCDs/LCDs as criteria for medical necessity reviews
  • Work with non-clinical team to obtain additional clinical information, as needed
  • Approve requests that meet eligibility, benefit, and medical necessity criteria
  • Refer cases to the Medical Director that do not meet medical necessity criteria
  • Refer cases to independent consultants or IROs, when necessary
  • Communicate outcomes of UM authorization reviews, both verbally and in writing
  • Process administrative and clinical appeals and refer as needed to the Medical Director
  • Maintain compliance with all accrediting agency standards such as NCQA, CMS and State agencies

REQUIREMENTS

  • Active, unrestricted Registered Nurse license
  • Minimum of 3 years of acute care clinical nursing
  • Minimum of 2 years of UM experience in a managed care, payor environment
  • Ability to interpret benefit language and apply medical necessity criteria to review requested services
  • Experience with Medicare and Medicaid (not required, but highly desirable)
  • Experience with UM authorizations and appeals for DMEPOS (not required, but highly desirable)
  • Verbal and written communication skills to convey information clearly and consistently

EMPLOYEE BENEFITS

  • Competitive compensation with bonus opportunity
  • 401(k) eligibility
  • Medical, Vision, Dental Benefits
  • Standard business hours
  • Paid Time Off (PTO); able to start using acquired time 90 days after hire
  • Collaborative and engaging office environment
  • Opportunity to be a key member of a rapidly growing company
  • Company sponsored events (holiday parties, sporting events, team building activities)
  • Company and department specific trainings

  

It is the policy of Integra Partners to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Integra Partners will provide reasonable accommodations for qualified individuals with disabilities.

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