Per Diem Utilization Management Nurse RN

UnitedHealth Group • Bangor, ME

116d • $28 - $50 • Remote

About The Position

The Utilization Management Nurse RN provides feedback as requested to enhance negotiations with payers. Assesses for accuracy in the assignment of patient class (status) to reflect congruence with clinical condition, physician intent, and utilization review outcomes with current rules and regulatory requirements. Supports the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation and support of medical necessity/level of care. Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities. Schedule: Flexible as it is per diem - must be able to work 7 AM - 3:30 AM or 8 AM - 4:30 PM EST - Rotating holidays and weekends - available two shifts per week. You will enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.

Requirements

• Associate's Degree (or higher) in Nursing
• Current and unrestricted RN Compact State licensure OR unrestricted RN license in state of residence and Maine
• 3+ years of acute clinical practice or related healthcare experience
• 1+ years of Utilization Management RN experience
• 1+ years of experience working with Cerner
• 1+ years of experience working with InterQual
• 1+ years of experience working with insurance and denials

Nice To Haves

• Bachelor's Degree in Nursing (BSN) (or higher)
• ACM, CCM or other certification applicable to utilization management within 3 years of hire
• Experience in utilization review and concurrent review

Responsibilities

• Validates authorization for all procedures/bedded patients UM pre-admission
• Ensures acquisition of pre-certification authorization, urgent/emergent authorizations, continued stay authorizations and authorizations for post-acute services from third-party payers
• Obtains commercial payer authorization within the contractual timeframe at the time of presentation, every third day or as needed
• Proactively reduces the risk of denials
• Manages concurrent cases to resolution
• Partners with Revenue Cycle team to support resolution of retrospective denials
• Conducts initial review and continued stay review every third day for Medicare
• Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information
• Confirms that orders reflect level of care, severity of illness and intensity of service utilizing Level of Care Criteria
• Conducts Level of Care review using electronic system and documents outcomes. Contacts payers as applicable
• Refers cases with failed criteria to Physician Advisor and appeals as necessary
• Completes stratification tool to identify simple vs complex patient population
• Deploys representative within Utilization Review team to handle audits (internal and external)
• Responsible for coordinating and conducting utilization / medical necessity reviews for all payers upon admission & concurrently throughout the inpatient admission in compliance with the NL EMMC Utilization Management Plan
• Ongoing collaboration with the Care Manager to ensure that patient's condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care
• Performs other duties as assigned or required

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

What This Job Offers

• Career Level: Entry Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree