RN UM Discharge, PlanningSummaCare - 1200 E Market St, Akron, OHFull-Time / 40 Hours / Days*In Area / Remote - After Training SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.
Summary:
Collaborates with other health care providers to evaluate medical necessity of care, for elective and emergency admissions, surgeries, diagnostic procedures and treatments. Coordinate the delivery of services in the most appropriate setting, and provide support for transitions between settings for plan members that meets organizational goals related to quality outcomes, member experience, and cost-efficiency, using approved medical criteria and regulatory guidelines.
Formal Education Required:
a) Bachelor Degree or may substitute with 4 years of like experience.
Experience & Training Required:
a) 3+ years performing same or similar responsibilities. Relevant experience includes: previous industry, utilization management/utilization review experience and care coordination.
Essential Functions: The following job specific requirements should discuss the essential duties and responsibilities required of the position. They should not replicate those duties and responsibilities discussed above.
1. Performs offsite or onsite admission, concurrent, or retrospective reviews for all levels of care (e.g. Inpatient Acute, LTAC, Rehabilitation, PHP, IOP, Skilled Nursing, Outpatient and Home Care).
2. Respond to incoming calls and transmissions via Rockwell.
3. Make accurate and consistent authorization determinations inclusive of collecting appropriate clinical information, applying appropriate medical criteria and consulting the Medical Director in accordance with policy and procedure.
4. Assist as needed with arrangements for safe member transition between levels of care.
5. Repatriates members from out-of-network setting or potential out-of-network setting to a network facility in a safe, timely and cost effective manner.
6. Maintains up-to-date work board of facility admission/discharge information to facilitate bed day reporting and timely claims payment. Maintains up-to-date UM event status and labeling in case management information system.
7. Identifies and refers at risk members to SummaCare care and condition management. programs.
8. Receives, reviews and routes incoming care management referrals to appropriate care management programs.
9. Evaluates targeted members for use of appropriate in-network providers, provides assistance in gaining access to in-network providers to achieve desired utilization and quality outcomes.
10. Participates in organizational and health system quality improvement and program activities as assigned by supervisor
11. Maintains working knowledge of NCQA, SummaCare Board of Trustees and regulatory (CMS, State Department of Insurance) standards relative to utilization and care management; consistently delivers UM and care management services in compliance with these standards.
12. Performs all job functions with integrity. Provides timely internal and external customer service in cooperative, professional, and respectful manner.
Other Skills, Competencies and Qualifications:
a) Registered Nurse (RN) state license in good standing. CCM/ACM certification or equivalent helpful.
b) Basic typing/computer skills needed to collect, assess, and enter data.
c) Demonstrate knowledge and skills necessary to provide care appropriate to the age of the members serviced. Takes ownership in identifying and obtaining education and training needed to meet needs of the members.
d) Work cooperatively with team members to accomplish HSM mission and goals.
e) Organize and manage time to accurately complete tasks within designated time frames in fast paced environment.
f) Maintain current knowledge of and comply with regulatory and company policies & procedures.
g) Maintain confidentiality of member health and business information.
h) Flexible: Ability to adjust work hours to meet business demands.
i) Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity
Level of Physical Demands:
1) Sit and/or stand for prolonged periods of time.
2) Bend, stoop, and stretch.
3) Lift up to 20 pounds.
4) Manual dexterity to operate computer, phone, and standard office machines.
Equal Opportunity Employer/Veterans/Disabled
$33.66/hr - $50.49/hr
The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.
Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits.
- Basic Life and Accidental Death & Dismemberment (AD&D)
- Supplemental Life and AD&D
- Dependent Life Insurance
- Short-Term and Long-Term Disability
- Accident Insurance, Hospital Indemnity, and Critical Illness
- Retirement Savings Plan
- Flexible Spending Accounts - Healthcare and Dependent Care
- Employee Assistance Program (EAP)
- Identity Theft Protection
- Pet Insurance
- Education Assistance
- Daily Pay
