RN Utilization Management (Relief)

St. Charles Health System • FL

97d • $47 - $71

About The Position

The Utilization Management Registered Nurse (RN) has well-developed knowledge and skills in areas of utilization management, medical necessity and patient status determination. The UM RN supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. The UM RN is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated and reported. When screening criteria does not align with the physician order or a status conflict is indicated, the UM RN is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. The UM RN is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes. Additionally, the UM RN monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences and designing and implementing process improvement projects as needed. This position does not directly manage any other caregivers.

Requirements

• Graduate of an accredited school of nursing.
• Current Oregon RN license.
• Three (3) years acute care clinical nursing experience.

Nice To Haves

• Bachelor’s degree in Nursing or Health Care related field.
• Five (5) years clinical experience in acute care facility.
• Two (2) years Utilization Management experience.
• Two (2) years’ experience working in electronic health records.
• Accredited Case Manager Certification (ACMA:ACM-RN).
• Commission for Case Manager Certification (CCMC:CCM).
• Case Management Nurse-Board Certified (CMGT-BC:ANCC).

Responsibilities

• Acts as an interdisciplinary team member within the UM Department.
• Performs pre-admission status recommendation review for multiple care settings.
• Ensures appropriate patient status upon admission and manages patient status conversions.
• Ensures completion of admission medical necessity reviews within 24 hours of admission.
• Completes concurrent inpatient medical necessity reviews at a minimum of every three days.
• Completes Observation medical necessity reviews at a minimum of every 12 hours.
• Completes Medicare extended stay reviews, as appropriate.
• Assigns an initial working DRG & GMLOS upon completion of initial medical necessity review for IP admission.
• Completes discharge reviews and ensures completeness of all prior medical necessity reviews and authorizations.
• Identifies and escalates all 1MN and 2MN Medicare IP stays.
• Collaborates with Care Management (CM) team, physicians, and payors as appropriate.
• Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM).
• Assists with discharge appeal process, as appropriate.
• Provides timely and continual coverage of assigned work area.
• Assists in the identification of Avoidable Days and communicates information with CM.
• Complies with all documentation requirements.
• Maintains a working knowledge of payor contracts and regulatory requirements.
• Participates in the delivery of regulatory forms to patients when appropriate.
• Communicates with insurance companies regarding the medical necessity of the admission.
• Actively participates in clinical performance improvement activities.
• Assists in the collection and reporting of resource and financial indicators.
• Supports the vision, mission and values of the organization.
• Conducts all activities with the highest standards of professionalism and confidentiality.

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree