Registered Nurse | Utilization Management

CentraCare•Saint Cloud, MN

1d•Hybrid

About The Position

As an integral part of the St Cloud Hospital Care Management team, the Utilization Review Nurse collaborates with other Care Management staff, physician/providers, physician advisors, and leadership to determine the most appropriate level of care for each hospital patient admission. Coordinates with the billing department, claims analysts, hospital insurance representatives, and Revenue Cycle department to ensure accurate claims are submitted for reimbursement. Responsible to conduct key components of the St Cloud Hospital Care Management and Utilization Review (UR) plans which includes activities to monitor for appropriate utilization of acute care services, identify and report quality indicators, required activities of utilization review, payer certification processes, and to identify performance improvement opportunities. Follows the guidelines of the Utilization Review Plan to assure cost-effective care and fulfills the requirement of the Center of Medicare and Medicaid Services Conditions of Participation (CoP) Utilization Review.

Requirements

Bachelor's Degree or higher degree in nursing required
Current licensure as a registered nurse in the State of Minnesota required
2 years Minimum of relevant clinical experience or other related experience in any of the following functions: utilization review, performance improvement, quality assurance, risk management or case management related experience is required
Acute care clinical experience required
Ability to work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families
Must possess a working knowledge of medical/legal issues in health care with special emphasis on documentation issues
Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement

Nice To Haves

Understanding of pre-acute and post-acute venues of care and post-acute community resources preferred
Knowledge and background with Joint Commission and CMS CoP is highly beneficial

Responsibilities

Determine the most appropriate level of care for each hospital patient admission.
Coordinate with the billing department, claims analysts, hospital insurance representatives, and Revenue Cycle department to ensure accurate claims are submitted for reimbursement.
Conduct key components of the St Cloud Hospital Care Management and Utilization Review (UR) plans.
Monitor for appropriate utilization of acute care services.
Identify and report quality indicators.
Perform required activities of utilization review.
Manage payer certification processes.
Identify performance improvement opportunities.
Assure cost-effective care following the guidelines of the Utilization Review Plan.
Fulfill the requirement of the Center of Medicare and Medicaid Services Conditions of Participation (CoP) Utilization Review.