RN - Utilization Management / Clinical Denial Management

About the role

As a member of the Utilization Management team, provides concurrent and retrospective clinical review of inpatient/observation medical records to evaluate the utilization of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation that accurately reflects the patient's severity of illness and intensity of service.

Responsibilities

• Demonstrates sound knowledge of Interqual criteria when conducting chart reviews.
• Utilize CERME to perform medical necessity reviews.
• Conduct Admission, Observation follow up, and Continued Stay reviews, identifying cases that documentation does not support severity of illness or intensity of service, thereby failing to meet criteria for admission.
• Refer cases to Secondary Medical Review, when appropriate, for assistance in determination of proper admission status, Observation follow up, or Continued Stay status.
• Demonstrate the ability to document proper order status in electronic health record.
• Demonstrate the ability to place a status order, at the direction of the provider, into the electronic health record.
• Demonstrate proficiency in the Medicaid review process, as well as the eQHealth system.
• Demonstrate knowledge of the IPO surgery list.
• Demonstrate ability to communicate review findings with Case Management, Social Services, Providers, or other ancillary departments as part of the continuum of care for the patient.
• Provide concurrent clinical review to UR agencies and communicates discharge plan as indicated.
• Discuss concerns, comments, length of stay, or coverage concerns from UR agencies or insurance providers, with Case Management, Social Services, or providers, or other ancillary departments as appropriate.
• Provide clinical updates or requests for information to UR agencies or insurance providers in a timely manner.
• Demonstrate proper documentation of communication with UR agencies and insurance payers, physicians, Case Management, Social Services, or other Ancillary Departments, into the patient’s Electronic Health Record.
• Participates in Utilization Management process for retro reviews, denials, P2P notifications to providers and follow up, and appeals.
• Utilizes E.HR as applicable to assist in denial management as requested.
• Completes follow up calls to UR agencies and insurance providers for certification of days as necessary.
• Act as a resource to ED/Surgery staff on weekends, in reviewing intensity of service, severity of illness, and documentation to support admission status when requested.
• Act as a resource, when requested, to those who may need Utilization Management support or assistance, in providing for the continuum of care for the patient.
• Create a welcoming environment for the person’s served.
• Effectively manage positive relationships with staff, physicians, ancillary staff, and third party payers.
• Maintain and complete accounts on multiple work queues in electronic medical record.
• Monitor and complete requests in work queue for clinical information.
• Prepare/fax documents for review, to third party payers.
• Ensure receipt of documents.
• Document sending of clinical information in patient chart.
• Monitor/document third party payers approved days, denials, requests for further information.
• Communicate opportunities for Peer to Peer from third party payers, with our physicians (at Methodist/Proctor/Pekin).
• Document requests/results of Peer to Peer conversations in patients electronic health record.
• Other duties as assigned, to meet the day to day operational needs of Utilization Management.

  Qualifications

  • Educational Requirements: College Diploma: Nursing Certification & Licensure Requirements: Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR), Licensed Practical Nurse (LPN) - Illinois Department of Financial and Professional Regulation (IDFPR)
  • Use of usual and customary equipment used to perform essential functions of the position.
  • Upon Hire: Other Requirements: Writes, reads, comprehends, and speaks fluent English, Microsoft Office Computer knowledge skills, Multicultural sensitivity, Possesses courteous and effective telephone etiquette, Possesses ability to prioritize and maintain organization, Strong communication skills.
  • Work Experience: Acute care.

  Benefits

  The compensation range for this position is $35.87 per hour - $58.37 per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.