RN -Utilization Management /Clinical Denial Management
Carle Health•Peoria, IL
•$36 - $58•Onsite
About The Position
Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of the Carle Foundation Hospital. Facilitates the care of patient by insuring that admissions and continued days are medically necessary, cost-effective, and provided in the appropriate level of care to qualify for reimbursement.
Requirements
- College Diploma - Nursing
- Registered Professional Nurse (RN) License Illinois Upon Hire
- Satisfactorily complete all required continuing education regarding the care of acute stroke patients.
- Able to establish professional relationships with all healthcare providers, work independently and collaborate, have strong communication and organizational skills and attention to detail.
Nice To Haves
- Case Management Certification preferred.
Responsibilities
- The UM staff RN will function within the IP Care Coordination Department to ensure that the most cost-effective and appropriate use of health care services for patients treated by Carle Foundation Hospital.
- Ensures efficient patient flow and throughput
- Initial assessment of all new patients for correct status (admission/observation/outpatient) based on UR medical necessity criteria.
- Performs concurrent reviews of all patient charts to ensure proper resource utilization as necessary to identify practice trends.
- Keeping LOS within patients working DRG.
- Send clinical documentation to insurance companies per their request.
- Communicate with physicians on status changes and documentation.
- Refers cases for secondary review when appropriate.
- Refers cases for escalated medical review when services do not meet medical necessity criteria and/or appropriate level of care.
- Documents utilization reviews/issues in appropriate locations, including but not limited to case management/utilization review software.
- Track Avoidable days.
- Educates and assists physicians in resource utilization.
- Participate in extended care reviews and attend meetings.
- Review cases for potential quality indicators and refers to UM Leadership.
- Works with Appeal staff to actively appeal cases concurrently and retrospectively.
Benefits
- Comprehensive benefits package
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
