RN - Utilization Management Analyst
About The Position
MU Health Care is looking for a Utilization Management Analyst RN to join our team. The ideal candidate will possess exceptional communication skills, the ability to collaborate effectively with healthcare teams, and a deep understanding of government and private insurance payer guidelines. Your role will involve overseeing patient admissions, conducting reviews, and ensuring that care is medically necessary and efficient. You'll play a vital role in maximizing reimbursements for hospital services, all while advocating for patients and educating both staff and physicians on utilization issues. Join us in making a difference in healthcare while enhancing your clinical expertise and critical thinking skills. This is more than a job; it's a chance to shape the future of healthcare at MU Health Care.
Requirements
- Missouri Board of Nursing RN or Nurse Licensure Compact multi-state RN. When primary state of residency changes, compact state RNs must apply under new state of residency within thirty (30) days.
- Two (2) years of hospital clinical experience or two (2) years of current utilization review experience.
- Excellent written and verbal communication skills.
- Knowledge of government and private insurance payer guidelines and regulations.
- Knowledge in the application of InterQual and/or Milliman Criteria.
Nice To Haves
- Experience in tertiary care and/or a teaching hospital.
- Experience in conflict resolution strongly desired.
- Additional license/certification requirements as determined by the hiring department.
Responsibilities
- Monitor unscheduled admissions to ensure appropriate patient type, timely notification of payor, and identify appropriate target LOS.
- Pre-certify/preauthorize process as assigned.
- Monitor 23-hour observation to ensure conversion to inpatient status if appropriate or discharge.
- Assist with denial and appeal process. Document avoidable delays/days.
- Monitor and develop plans of action for patients with extended LOS over that allowed by the benefit plan.
- Monitor admissions according to all third-party criteria.
- Perform retrospective reviews as necessary.
- Collaborate with payor reviewers to ensure appropriate utilization of resources.
- Provide formal and informal education/in-services to staff and physicians on utilization issues.
- Assist with the development/revision of policies, procedures, and service standards.
- Participate in ongoing efforts to improve the utilization management process and CQI activities as assigned.
- Maintain current knowledge of payor criteria/policies related to utilization of resources.
- Audit charts per request of Patient Accounts and Revenue Recovery. Compile data and statistics for monthly and annual reporting.
- Maintain clinical expertise in Medical-Surgical, Pediatric, and Psychiatric clinical care. Escalate payer issues to attending physicians and hospital leadership.
- Actively collaborates with the health care team regarding the course of care delivery to ensure timely discharge. Serve as liaison between the payer and the physician.
- Utilize medical discernment and critical thinking skills on a case-by-case basis as required for reimbursement maximization.
- Participate in formal education of payer criteria policies to medical students and Residents.
- May complete unit/department specific duties and expectations as outlined in department documents.
Benefits
- Health, vision and dental insurance coverage starting day one
- Generous paid leave and paid time off, including ten holidays
- Multiple retirement options, including 100% matching up to 8% and full vesting in three years
- Tuition assistance for employees (75%) and immediate family members (50%)
- Discounts on cell phone plans, rental cars, gyms, hotels and more
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
