Utilization Management Nurse

Responsibilities

• Cover Utilization Review and Determine Appropriate Level of Care
• Apply evidence-based medical necessity criteria, validate admission status, and ensure all inpatient, observation, and outpatient-in-a-bed cases meet criteria.
• Collaborate proactively with physician advisors and attending providers for accurate level-of-care decisions and authorization of hospital days.
• Manage Denials, Compliance, and Quality Improvement Activities
• Participate in denial management and peer review processes, identify compliance or ethical issues, and contribute to quality and safety initiatives.
• Achieve interdisciplinary collaboration through daily huddles, multidisciplinary rounds, and patient care discussions.
• Serve as a resource to the care team on utilization, documentation, and admission requirements.
• Maintain accurate and timely documentation in Midas, Epic, and other required systems.
• Perform additional duties as assigned.

Requirements

• Utilization Management and Pediatric Nursing experience preferred.

Qualifications

• Technical Expertise: Experience in inpatient clinical is required. Experience in pediatrics is preferred.
• Organizational Expertise: Experience working with all levels within an organization is required.
• Experience in Healthcare: Experience in healthcare is required.
• Software Proficiency: Proficiency in MS Office [Outlook, Excel, Word] or similar software is required.

Education and Experience

• Education: Bachelor's in nursing [BSN] is required. For employees hired after July 1, 2013, BSN is required or must be obtained within 5 years from date of hire.
• Certification: Registered Nurse licensure is required.
• Years of Relevant Experience: 3 years is required.
• Years of Supervisory Experience: None.