RN, Utilization Management

Responsibilities

• Works collaboratively with various departments across the entire health care system to review clinical documentation, utilizing evidence based criteria to support medical necessity and appropriate level of patient care for services provided.
• Reports outcome trends and patterns to UM leadership to help identify educational opportunities and performance improvement initiatives across the health care continuum.
• Adapts to process changes and assists with education efforts that support ongoing improvement.

Requirements

• Determines level of care per regulatory requirements.
• Provides level of care notifications to patients and families as needed.
• Works collaboratively with payers to ensure authorization for dates of service.
• Collaborates with HIM, providers, Financial Counseling and Patient Financial Services.
• Maintains awareness of UM hold bills and unplanned readmission reports.
• Conducts initial and concurrent reviews, utilizing evidence based criteria through Interqual.
• Supports discharge appeal process.
• Responsible for departmental denials and appeal activity.
• Documents according to regulatory guidelines and UM RN workflow protocols.
• Conducts clinical documentation improvement efforts through query process.
• Maintains productivity expectations established by UM department.
• Supports and provides ongoing educational needs for all UM customers.

Qualifications

• Associate's degree in Nursing and 3 years of acute hospital experience required.
• Bachelor's degree in Nursing (BSN) preferred.
• Or equivalent combination of education and experience.
• Utilization Management experience preferred.

Skills

• Database experience including: Interqual, Sharepoint, eRecord, ePARC, Cobius preferred.

Benefits

• The referenced pay range represents the minimum and maximum compensation for this job.
• Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Pay

• $80,923.00 - $105,208.00

Schedule

• UR - Day (United States of America)