UM RN Reviewer

Core Job Responsibilities

• Perform medical necessity reviews using InterQual and/or other medical decision support software designated by the organization and rendering determinations appropriately within established regulatory timeframes.
• Accurately documents required information into necessary systems according to department documentation standards and following all department workflows including correspondence to members and providers (ie. PCP notification of inpatient admissions).
• Documentation of discharge planning within 24 to 48 hours of admission notification.
• Completes admission authorization, out of network transfers, initiates concurrent authorization, completes retrospective authorization and minimizes financial risk by maintaining timely communication with all payors.
• Generates and process daily admission logs and appropriate denial letters as per UM process.
• Performs critical analysis of decisions/determinations while supporting effective team collaboration and communication.
• Affixes to corporate compliance policy, department guidelines/policies and all applicable laws and regulations.
• Collaborates with the Case Management/Care Coordination nurses to ensure members who are eligible for case management are identified and enrolled as well as to ensure contact post hospital discharge.
• Works closely with the health center staff, providers, hospitals, MCOS, and other outside vendors concerning scope of benefits, referrals, precertification/authorizations, and network facility participation.
• Participates in department committee meetings, webinars, training, projects and special assignments for cross-coverage purposes to meet strict authorization processing deadlines.

Requirements/Preferences

• Associate required; Bachelors (Preferred)
• Registered Nurse (RN); current licensure in Illinois
• Minimum 1-year nursing experience inpatient or ambulatory (Preferred)
• Minimum 1-year Utilization Management experience preferred
• Minimum 1-year Case management experience preferred
• Experience with Epic System (EHR), InterQual a plus
• Intermediate proficiency in Microsoft Office products

About the Role

We are an equal opportunity employer. All qualified applicants will receive consideration for employment. We do not discriminate for any reason. We welcome talented individuals who believe in our mission, drive the organization forward, and recognize the positive impact they can bring to our communities.

Benefits

The pay ranges provided represent the minimum to mid-range for positions. Actual compensation will be determined based on a combination of factors including years of experience, educational background, market conditions, and available grant funding.