Utilization Management RN-Acute

Nature and Scope

Congratulations, you are now a Utilization Management RN at Renown Health. Your primary responsibility is to promote appropriate utilization, high-quality care, and cost-effective outcomes. You will conduct medical certification reviews for acute care facilities and services, ensuring that services are medically necessary and compliant with national and local coverage determinations.

• Use nationally recognized, evidence-based guidelines approved by the medical staff to recommend levels of care to physicians and serve as a resource on admission qualifications, resource utilization, and documentation improvement opportunities.
• Provide information to the care team (including RNs, physicians, and case managers) about certified length of stay and reimbursement issues to ensure appropriate and timely dispositions of clients.
• Document all chart and phone reviews, identify and communicate potentially avoidable or non-reimbursed days, and monitor quality indicators such as readmissions.
• Deliver non-covered letters as required by payers and/or regulatory compliance.

Knowledge, Skills & Abilities

• Strong interpersonal communication skills, both verbal and written.
• Knowledge of applicable regulatory requirements and community resources.
• Understanding and resolving complex problems through critical thinking.
• Continuous learning and staying updated with new developments and acquiring the necessary knowledge to keep skill sets current.
• Ability to work under stress and meet deadlines.

Minimum Qualifications

• Education: Working-level knowledge of the English language, including reading, writing, and speaking English. Appropriate education to obtain and maintain Registered Nurse licensure in the State of Nevada.
• Experience: 1 year previous managed care and/or case management experience, including acute hospital case management, is preferred. One year in a hospital setting is required.
• Licenses: Ability to obtain and maintain State of Nevada Registered Nurse license.
• Certifications: Utilization or Case Management Certification preferred. Certification in Case Management (CCM), Certified Managed Care Nurse (CMCN), or ABQAURP HCQM is preferred.
• Computer / Typing: Must possess or be able to obtain within 90 days the computer skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.