Care Transitions Utilization Review RN, Per Diem

Position Summary

In conjunction with the admitting/attending physician, the Utilization Review RN assists in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed.

Essential Functions and Responsibilities

• Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
• Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity.
• Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
• Works collaboratively with RN Case Managers to expedite patient discharge.
• Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues, including appeals, third-party payer certification, and denied cases.
• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications, establishing personal networks; participating in professional societies.
• Complies with federal, state, and local legal and certification requirements by studying existing and new legislation, anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.
• Reviews data of specific to utilization management functions and reports as requested.

Qualifications

• Licensure as a Registered Nurse (RN), Massachusetts
• Three years of recent clinical or utilization management experience
• Possession of a Bachelor’s degree in nursing or related healthcare fields preferred
• Competence in standardized medical necessity criteria
• Three years of recent case management or utilization management experience
• ACM, CCM, or CMAC Certification

Knowledge, Skills, And Abilities

• Demonstrates expertise in the utilization management principles, methods, and tools and incorporates them into the daily operations of the organization.
• Understands, interprets and explains, and uses data for utilization management activities.
• Applies the principles and methods necessary to perform utilization management functions.
• Competency in applying the principles, methods, materials, and equipment necessary in providing utilization management services.
• Demonstrates clinical expertise to effectively facilitate the evaluation of the level of care required.
• Develops and maintain strong collaborative working relationships with physicians, nursing colleagues, and other clinical professionals.
• Provides and receives feedback in a positive and constructive manner.
• Absorbs and applies knowledge of care delivery systems across the continuum of care, including trends and issues in care reimbursement.
• Possesses mid to high-level proficiency in navigating the Electronic Medical Record and applications related to utilization management.

Pay Range

The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.