PRN ED Utilization Management Nurse (Remote)

University Hospitals•Cleveland, OH

8h•Remote

About The Position

The PRN ED Utilization Management Nurse will cover shifts associated with PTO, typically 10 PM - 10 AM. This role involves managing recommendations for patients being admitted to the hospital setting using criteria such as MCG and IQ, with training provided. The nurse will collaborate and coordinate with the healthcare team, patient, and family to ensure timely and efficient delivery of workflow and services. Key goals include supporting positive patient health outcomes, increasing patient/healthcare team satisfaction, improving inpatient throughput and appropriate length of stay, enhancing communication and adherence to regulatory requirements, reducing inappropriate level of care and inpatient bed day denials, ensuring continuity and coordination of care, securing appropriate and timely authorization for level of care, decreasing denials, and ensuring appropriate reimbursement. The position requires performing and documenting timely and accurate concurrent review of records, discussing care plans with ED physicians for LOC decisions (inpatient admission or outpatient observation services), and supporting effective communication of physician decisions for accurate registration status and patient notices. All activities must focus on continuous quality improvement, supporting UHC quality initiatives, and complying with regulatory requirements. The role also includes performing other assigned duties, complying with policies and standards, and maintaining Protected Health Information (PHI) securely.

Requirements

Graduate of an accredited school of Nursing
3+ years of clinical experience (acute care)
1+ years of experience in utilization management/case management in an acute care setting
Must have sound clinical knowledge base of the population to be served
Detail-oriented and organized, with good analytical and problem solving ability
Notable client service, communication, presentation and relationship building skills
Ability to function independently and as a team player in a fast-paced environment
Strong written and verbal communication skills
Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.)
Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines
Registered Nurse (RN), Ohio and/or Multi State Compact License Upon Hire

Nice To Haves

Bachelor's Degree
Experience as an ED nurse
Experience in ED utilization management/case management
Experience with Interqual or Milliman criteria
Knowledge of Medicare, Medicaid and commercial payer regulations
CM software proficient
CM certificate

Responsibilities

Cover shifts to assist with coverage of PT and FT nurses taking PTO, typical shift is 10P-10A
Manage recommendation of patients being admitted to the hospital setting using criteria set (MCG and IQ)
Collaborate and coordinate with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks
Support positive patient health care outcomes
Increase patient/health care team outcomes and satisfaction
Improve inpatient throughput and appropriate length of stay
Improve communication, awareness and adherence to regulatory requirements associated with utilization
Support for inappropriate level of care and decreased inpatient bed day denials
Ensure continuity and coordination of care
Ensure appropriate and timely authorization for level of care
Decrease denials
Ensure appropriate reimbursement
Perform and document timely and accurate concurrent review of records and discuss plan of care with ED physicians to support the decision making process with regard to LOC decisions inpatient admission or outpatient observation services
Support effective and timely communication of the physician decision regarding inpatient admission or outpatient observation services for accurate registration status, and delivery of appropriate notices to patient when required
Conduct all CM activities with a focus on continuous quality improvement in a manner that is supportive of UHC quality initiatives and in compliance with applicable regulatory requirements
Perform other duties as assigned
Comply with all policies and standards
Abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients