Registered Nurse (RN) - Utilization Management Nurse

Rochester Regional Health

1d•$40 - $55•Onsite

About The Position

SUMMARY: Review all inpatient medical necessity denials for the health system based on InterQual and/or CMS guidelines. Responsibilities include managing the workflow with the standard UM sources for potential inpatient medical necessity denials. Assists and guides the Center Business Office with any billing issues involving inpatient medical necessity patient class as needed. Responsibilities include concurrent (as needed) and retrospective reviews. The Utilization Management Nurse will act as a resource on denial management as needed across the organization.

Requirements

3 years of acute hospital care, Case Management and/or Utilization Management experience
Excellent oral and written communication and interpersonal skills
Good understanding of medical management techniques and processes
Strong organizational and problem solving skills
Electronic Medical Record experience (Epic)
Able to adapt and be flexible to changes based on health system needs
Current New York State Registered Nurse License

Nice To Haves

BS degree
Knowledge of Federal and State regulations (DOH, Medicaid/Medicare)
Knowledge of third party payer and/or managed care payment principles helpful
Case Management Certification
At least 3 years RN experience preferred

Responsibilities

Review standard UM sources for potential inpatient medical necessity denials.
Review patient class in the event manager, assist with LOC determination retrospectively, and changes patient class as it relates to the Provider order for billing purposes.
Meet all appeal deadlines for all payers.
Demonstrates fiscal responsibility.
Prepare the UM review findings, initiate and 1st, 2nd, and/or arbitration appeals as needed.
Document in all areas that an appeal has been initiated or no appeal is necessary per UM reviews.
Track and monitor all denials, appeals, arbitration responses to payers/audits.
Participates in periodic denial meetings with Physician Advisors to review the denials that do not meet InterQual and/or CMS guidelines for his/her recommendation regarding appeal options.
Manages confidential information in accordance with RRH policy and procedures.
Retrospectively communicates clinical information to payers, severity of illness, and intensity of service and plan of care.
Maintains accountability to hospital, state, and federal regulations, and professional standards.
Initiates alternate level of care determinations in compliance with regulatory and contractual agreements.
Actively participates in Education sessions.
Actively participates in analysis of utilization and quality trends and makes recommendations to management on opportunities for improvement.
Using nationally recognized standards of care and guidelines.
Prioritizes multiple projects and tasks.
Be able to work independently with minimum direction.
Act as a resource for utilization review stakeholders and assists team members in clinical problem solving.