IntusCare
Healthcare
UtilizationManagementNurse
Neural analysis suggests this role is
optimal for Mid candidates.
“Utilization Management Nurse at IntusCare. Skills: Utilization management, Care coordination, Risk adjustment, Population health. Review service utilization. Guide care decisions”
What You'll Achieve.
Deliver exceptional care; Strengthen financial performance; Stay compliant; Improve outcomes for dual-eligible seniors; Ensure high-quality, cost-effective, and compliant care; Driving efficient and timely transitions of care; Driving efficient and timely discharge plans and transitions of care; Assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions; Ensure issuance of a written determination consistent with the PACE program policies
Industry & Context.
Problem solving
What They're Looking For.
Must Have
Current RN license, 3 to 5 years of utilization management experience
Nice to Have
Proven experience working in risk based integrated models of care, Ability to use data to drive decisions and collaboration with internal and external stakeholders
What You'll Do.
Review service utilization
appropriate transitions across care settings
Ensure services are medically necessary
Ensure services are aligned with care plans
Ensure services are consistent with PACE regulations and best practices
Maintain program integrity
Improve participant outcomes
Support the delivery of coordinated
Adherence to PACE program service authorization policies
Concurrent review of all hospital admissions
Retrospective review of inpatient admissions under 48 hours
Review of all subacute and SNF admissions
Coordination and review of all other services delivered by contracted providers
Advocate quality care and enhanced quality of life
Advocate decreased hospital stay when appropriate
Maintain accurate records of all patient related interactions
Lead the provider appeals process
How You'll Work.
Team & Collaboration
Partner closely with PACE Interdisciplinary Teams, Medical Directors, and provider networks; Collaboration with internal and external stakeholders; Collaboration with the PACE Program's Medical Director
Communication Scope
Excellent communication
Full Job Description
About IntusCare IntusCare is the only end-to-end ecosystem built specifically to help Programs of All-Inclusive Care for the Elderly (PACE) programs deliver exceptional care, strengthen financial performance, and stay compliant. IntusCare replaces outdated technology and manual workarounds with purpose-built solutions for care coordination, risk adjustment, population health, and utilization management. IntusCare empowers teams to take control of their operations and improve outcomes for dual-eligible seniors – some of the most socially vulnerable and clinically complex individuals in the US healthcare system. Role Overview The Utilization Management Nurse plays a critical role in ensuring high-quality, cost-effective, and compliant care for PACE participants supported by IntusCare. This individual partners closely with PACE Interdisciplinary Teams, Medical Directors, and provider networks to review service utilization, guide care decisions and support timely, appropriate transitions across care settings. Blending clinical expertise with analytical thinking, the Utilization Management Nurse ensures services are medically necessary, aligned with care plans and consistent with PACE regulations and best practices. This role is essential to maintaining program integrity, improving participant outcomes and supporting the delivery of coordinated, value-based care. Responsibilities - 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. - Active involvement in various aspects of the utilization management process, including: - Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and
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