Utilization Management Nurse

About the Role

Utilization Management Nurse provides comprehensive assessment, coordination, implementation, and reporting of complex clinical data. The Utilization Management Nurse assesses the patient's plan of care and progress throughout an acute care admission. The intensity of assessment is situational and appropriate based on payer requirements. This position is accountable for the communication of the clinical services delivered to identified payers and agencies.

Responsibilities

• Determines medical necessity, appropriateness of admission, continuing stay, and level of care using clinical information, clinical criteria, and third-party information. Intervenes when determinations are not aligned with clinical information, clinical criteria, or third-party information to resolve the situation.
• Monitors and updates accommodation codes, patient class (observation/inpatient), and admission type to ensure capture of status and level of care.
• Validates admission and continuing stay criteria with third-party payers as well as the Attending Physicians.
• Updates discharge list for last covered day. Calls discharge date to payer or submits discharge review.
• Completes all new admission reviews within 1 business day.
• Confirms pre-certification or authorization for admission.
• Utilizes InterQual Criteria with each new admission as well as with every denial.
• Informs the case manager of any issues or plans noted in the documentation.
• Refers Self-Pay cases to Family Health Coverage Program (FHCP) and/or Social Work to determine if coverage is pending or if an application for coverage has been made.
• Conducts concurrent reviews on the first uncovered day unless specified otherwise by the payer. Reviews include current medical status with supporting labs, study results, treatments relevant to the level and acuity of care, procedures, surgeries, plan of care, and patient progress toward goals, as well as any contributing social, educational, or discharge planning issues.
• Provides reviews requested after patient discharge within 24 hours of discharge.
• Ensures determinations are received and documented within 24 hours or on the next business day following the review or provision of additional information.
• Responds to all requests from the payer on the day received or within one business day.
• Manages denials by notifying the physician advisor for a Peer-to-Peer call and updating the clinical team.
• Contacts clinical providers to clarify the level of service and/or severity of illness if not clearly reflected in patient progress notes.
• Notifies the CM physician advisor for a 2nd level review when continued inpatient stay cannot be justified and a plan for an appropriate level of care is not implemented.
• Educates clinical providers when documentation does not support medical necessity for acute level of care or when the admission was not pre-certified as required by the health plan.
• Collaborates with third-party payers to prevent denial of payment and proactively addresses issues contributing to potential denials.
• Supports the effective prevention and management of denials, including providing requested information as part of the appeal process.
• Establishes and maintains rapport with Revenue Cycle teams to facilitate timely and appropriate reimbursement for services provided.
• Adheres to established departmental policies, procedures, and objectives.
• Communicates with families regarding denials and insurance status.
• Enhances professional growth and development by accessing educational programs, job-related literature, in-service meetings, and workshops/seminars.
• Maintains established department/hospital/system policies and procedures, directives, safety, environmental, and infection control standards appropriate to this position.
• Demonstrates a courteous and professional manner through interactions with internal and external customers.
• Integrates clinical nursing acumen with evidence-based literature in decision-making.
• Exemplifies a professional image in appearance, manner, and presentation.
• Engages in self-performance appraisal, identifying areas of strength and areas for professional development.
• Researches, selects, and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
• Adapts behavior as needed to the specific patient population, including respect for privacy, method of introduction, explanation of services, requesting permissions, and communication style.
• Performs other related duties as assigned.

Requirements

• Technical Diploma in Nursing - Required
• Bachelor's Degree in Nursing - Preferred

Qualifications

• At least five (5) years of experience as a clinical nurse in an acute care setting - Required
• Prior experience as a Case Manager or Utilization Reviewer - Preferred

Skills

• Excellent communication and demonstrated organizational skills (Required proficiency)
• Ability to work effectively with all departments and all levels of CHOP professionals (Required proficiency)
• Ability to work independently or within a team structure (Required proficiency)
• Must be very organized and able to work independently (Required proficiency)
• Ability to establish priorities among multiple needs, meet deadlines, and maintain standards of productivity (Required proficiency)
• Knowledge of payer(s) admission processes (e.g., verification of benefits, admissions notification) (Required proficiency)
• Knowledge of payer portal navigation (Required proficiency)
• Ability to effectively negotiate with internal and external providers of patient care services (Required proficiency)
• Sound problem-solving skills (Required proficiency)
• Excellent customer service orientation and strong interpersonal skills (Required proficiency)
• Computer skills and a working knowledge of Microsoft Office Products (Required proficiency)

Licenses and Certifications

• Registered Nurse (Pennsylvania) - Pennsylvania State Licensing Board - upon hire - Required

Pay

Salary Range: $92,100.00 - $117,400.00 Annually. Salary ranges are shown for full-time jobs. If you're working part-time, your pay will be adjusted accordingly.