ISNP Utilization Management Nurse

General Purpose: The individual holding this position is required to support and demonstrate their commitment to the Longevity Health Plan Statement of Purpose, which is: To improve the health and quality of life of nursing home residents by caring for their unique medical, social, and emotional needs.

The ISNP Utilization Management Nurse is supervised by a Utilization Management Supervisor and is responsible for evaluating a member’s clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for inpatient and outpatient services based on independent analysis of those medical records and application of appropriate medical necessity criteria. The ISNP Utilization Management Nurse is empowered make clinical determination decisions by independently authorizing services deemed medically necessary based on the independent review using InterQual, MCG, National and Local Coverage Determination Guidelines and to refer and consult with a medical director for those services that do not meet medical necessity criteria. The ISNP Utilization Management Nurse directly interacts with providers to obtain additional clinical information and participate in the development and modification of medical necessity criteria and policies for the company and its customers, as well as assisting management with development of short‐ and long‐term business objectives. Throughout the performance of their duties, the ISNP Utilization Management Nurse provides a front‐line regulatory/compliance function in their evaluation and application of the criteria. The ISNP Utilization Management Nurse is supported by administrative staff responsible for compiling information, data entry and other tasks to build cases and facilitate their work so that the ISNP Utilization Management Nurse can focus the majority of their time on applying their medical knowledge to medical necessity reviews. This job description is intended to provide a general overview of the position, while recognizing that actual day‐to‐day duties may vary for the ISNP Utilization Management Nurse depending on individual factors such as education, experience, skills, supervisor, and caseload.

Key Tasks and Responsibilities:

Receives requests for authorization of services, including inpatient hospital admissions, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non‐ participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination) in the Health Plan designated system accurately and timely.
Verifies and documents member eligibility for services.
Communicates and interacts on a real time basis via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).
Utilizes technology and resources (systems, telephones, etc.) to appropriately support work activities. Applies Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.
Applies submitted information to Plan authorization process (utilizing Interqual, MCG, NCDs, LCDs or medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.
Coordinates with the referral source if insufficient information is available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows Plan process for requesting additional information.
Refers cases to Plan Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.
Documents case activities for Utilization determinations and discharge planning coordination in Plan IT system in a real time manner (as events occur). Completes detail line as indicated. Completes ASF per policy.
Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely manner and saves in the appropriate system defined area.
Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
Submits appropriate documentation/clinical information to clerical support for record keeping and documentation requirements.
Recognizes opportunities to obtain input from assigned care coordination/Advanced Practice Provider and refers accordingly.
Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.
Participates in the appeals process.
Maintains awareness and complies with Plan authorization timeliness standards based on Health Plan/NCQA requirements.
Actively participates in weekly review of extended hospital stay members and provides clinical updates and discharge planning needs to the team.

Credentials & Coverage:

Licensed as a nurse. Registered Nurse Preferred.
Valid state driver’s license with a good driving record and proof of automobile insurance required.
Auto liability insurance coverage per minimum required by home state.

Education and Training:

Associate’s degree in nursing required, bachelor’s degree preferred.

Knowledge and Experience:

3‐5 years’ experience as a nurse.
Minimum of 2 years Health Plan utilization management experience OR equivalent.
Excellent verbal and written communication skills.
Excellent computer skills, Clinical Platform/MS Office Products.
Minimum of one year of supervisory experience in leading a team.

Company Overview:

Founded in 2018, Longevity Health started as an Institutional Special Needs Plan (ISNP), a type of Medicare Advantage health plan that addresses significant unmet needs of long-term institutionalized members who reside in nursing homes. Through rapid growth from 2018 to 2022, we expanded our market footprint and currently offer ISNP Medicare Advantage plans in Colorado, Florida, Illinois, Michigan, New Jersey, New York, and North Carolina.

In 2023, we expanded our service offerings to the broader health plan market. In addition to our existing markets where we are both the ISNP and the care management team, we are now partnering with National Carriers on their offered ISNP plans in Ohio, Pennsylvania, upstate New York, Georgia, South Carolina, and Texas, with implementations in progress for several other additional US states. This allows us to utilize our core skills of supporting clinical post-acute needs of this vulnerable senior population Currently 13 markets and expanding rapidly.

Company Disclaimers:

Longevity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.

It is the policy of Longevity Health to follow Federal and / or State regulations surrounding COVID vaccinations. While CMS guidelines have been relaxed, there are some LHP facilities which will still require staff be vaccinated in an effort to protect the health of the members / patients we serve. If your assigned location(s) require all staff to be fully vaccinated, you are required to obtain and / or provide documentation related to your COVID vaccination. To confirm whether your assigned location(s) require COVID vaccinations, please refer to the Facility Guide Job Aid located on Longevity Health Plan’s intranet site.

The Company will engage in an interactive process with individuals who cannot be vaccinated for medical or sincerely held religious beliefs to determine if a reasonable accommodation can be made. While an exemption/accommodation may be initially granted, if at any time during employment, it is determined that an exemption/accommodation that has been granted is no longer considered a reasonable accommodation, it can result in employment with the Company ending.

Candidates must meet the Company’s hiring criteria which include a pre-employment background and drug screening.

Longevity Health offers a competitive compensation and benefits package which includes medical, dental, vision, short and long-term disability, life insurance, and 401(k).

Submission of false information during the application process may result in immediate termination of employment without notice.