RN - Utilization Management - FT

Summary

The Registered Nurse (RN) Utilization Management (UM) in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, payers, and the Guthrie Clinic health system business office, is responsible for developing, coordinating, and maintaining UM processes based on regulatory and reimbursement requirements of commercial and government payers. The UM RN responsibilities include performing a variety of concurrent and retrospective UM-related clinical reviews and revenue cycle functions ensuring appropriate status and corresponding reimbursement. The UM RN leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.

Experience

• BSN with a minimum of five years’ clinical experience in an acute health care setting preferred.
• RN with a minimum of five (5) years relevant acute care, clinical experience willing to pursue and complete a BSN may be considered.
• Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames.
• Knowledge of health benefit plans and related UM requirements preferred.
• Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes preferred.
• Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable.

Essential Functions

• Collaborate and set standards with registered nurse (RN) case managers (CMs) and outcome managers to ensure that all hospitalized patients have the correct admission status (inpatient, outpatient short procedure, etc.).
• Complete short stay work queue reviews and track and trend results for reporting and education purposes.
• Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.
• Maintain status determination tools and other UM tools and distribute to staff as needed.
• Prepare succinct, written clinical case summaries that include rationale for the recommended billing status.
• Serve as a resource person for RN CMs and others to ensure consistent and accurate patient status determinations for appropriate claim submission.
• Participate in UR Committee and UM activities.
• Aid in the preparation of discussion and appeal letters for Medicare/Medicaid medical necessity denials.
• Aid in the development, implementation, teaching, evaluation and revision of UM standards.
• Facilitate review of rejected medical claims using clinical evidenced based tools and peer-reviewed journals.
• Provide ongoing education to providers, CM, billing, and business office teams as related to UM, medical necessity, patient status, InterQual, non-coverage notifications, and other UM areas as indicated.
• Develop and provide individualized UM-related education as needed.

Pay

The pay range for this position is $37.50 - $53.06 per hour.