Quality & Utilization Management Care Coordinator

This position offers the possibility for remote/hybrid work

This position is responsible for conducting initial, concurrent, and retrospective reviews to determine the medical necessity of requested Service Authorizations according to accepted/approved criteria and following selected contractual and/or applicable utilization management and care management regulations from the Centers for Medicare & Medicaid Services (CMS), the Minnesota Department of Human Services (DHS), and Minnesota Statutes and accreditation requirements from the National Committee for Quality Assurance (NCQA). This position helps members navigate the continuum of care that facilitates the right care at the right time and place. As needed, this position supports PrimeWest Health’s Healthcare Effectiveness Data and Information Set (HEDIS ® ) program processes including, but not limited to, chart chases and abstraction identification. This is a highly collaborative position, involving frequent collaboration with medical directors and other staff members. All duties and responsibilities are conducted in collaboration with the Chief Senior Medical Director, the Director of Quality & Utilization Management, the Manager of Quality Management, the Utilization Management Manager, and the Member & Provider Services department.

Educational Requirements and Required Qualifications
1. At minimum, a registered nurse (RN) license; a bachelor of science in nursing (BSN) with a minimum of two years of experience in medical-surgical, home health, or Skilled Nursing Facility (SNF) nursing is preferred.
2. Experience in utilization management/utilization review is a plus.
3. Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required.
4. Flexibility and ability to handle multiple tasks. Demonstrated organizational skills and attention to detail. Ability to work effectively with a variety of people both within and outside of the organization. Excellent verbal and written communication skills.
5. Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 20 pounds.

PrimeWest Health is an Equal Opportunity Employer Committed to Diversity, Equity, and Inclusion