Utilization Management Nurse St. Luke's Health Plan

St. Luke’s Health System in is seeking a Utilization Management Nurse for St. Luke's Health Plan to join our team.

St. Luke’s Health Plan is a wholly-owned, not-for-profit subsidiary of St. Luke’s Health System, offering health insurance coverage for individuals, families and employers across south central and southwestern Idaho. Building on more than 120 years of committed service to Idaho, St. Luke’s Health Plan is on a bold and ambitious mission to redefine the coverage to care experience, removing barriers for both members and providers and creating a more seamless, hassle-free experience.

Summary:

This role is responsible for reviewing and assessing requests for medical procedures, treatments, services, and inpatient admissions to ensure they meet medical necessity criteria. This position plays a vital part in the timely and accurate review of preauthorization requests, facilitating the best possible care for St. Luke's Health Plan members while managing healthcare costs. It requires excellent written and verbal communication skills.

Responsibilities:

• Evaluate preauthorization requests from healthcare providers to determine coverage relative to benefits, medical necessity, appropriateness, and efficacy of requested medical services or procedures.
• Conduct clinical and concurrent reviews by analyzing medical records, diagnostic tests, and physician notes to make informed decisions regarding the approval or denial of preauthorization requests and inpatient admissions.
• Ensure that all decisions and approvals align with the company's medical necessity criteria, clinical guidelines, and evidence-based best practices.
• Collaborate with healthcare providers, members, and internal teams to gather additional information, clarify clinical information, or discuss decision outcomes.
• Maintain thorough and accurate records of preauthorization decisions, communications, and supporting documentation in compliance with company and regulatory standards.
• Strive to achieve prompt preauthorization decisions to support timely access to care for our members.
• Stay updated on evolving medical guidelines, standards, and industry trends to make well-informed and evidence-based decisions.
• Contribute to the enhancement of utilization management processes, procedures, and guidelines by identifying areas for improvement.
• Write and send notification to members and providers regarding utilization management determinations, using plain language that is easy for a layperson to understand.
• Perform other duties as assigned.

   

Qualifications:

• Education: Bachelor of Science in Nursing (BSN)
• Experience: 3 years relevant experience
• Licenses/Certifications: Current RN licensure in state of practice

   

At St. Luke’s, caring for people in the communities we serve is our mission – and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Virgin Pulse Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.

St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.

*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.