RN - Utilization Management Specialist

Sanford Health•Sioux Falls, SD

2d•Hybrid

About The Position

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. This role involves conducting level of care medical necessity reviews within patient medical records and performing utilization management (UM) activities in accordance with the UM plan to ensure compliance with accreditation/regulatory requirements. The specialist will complete and coordinate activities related to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes. This includes determining medical necessity, authorization, and continued stay reviews, including diagnosis and procedural coding for working diagnosis-related group (DRG) assignments. Workflows may include patient chart review, managing insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, and length of stay. The role ensures validation of the appropriate level of care for pre-admission surgical reviews prior to admission, using InterQual clinical decision support criteria. The specialist will determine appropriate action for cases not meeting departmental standards, requiring secondary review or escalation. Collaboration with physicians and other clinical professionals to promote medically necessary resource utilization and achieve fiscal outcomes is expected. The role also involves educating healthcare team members on trends, external regulations, and internal policies affecting resource utilization and prior authorization. Assistance with monitoring resource utilization, risk management, and quality of care, along with report preparation, correspondence, and record maintenance, is also part of the responsibilities. Ensuring services comply with professional standards, national and local coverage determinations (NCD/LCD), CMS, and state/federal regulatory requirements is crucial. Maintaining knowledge of payer standards for UM functions and authorization requirements is necessary. The role may involve assisting with special projects, upcoming initiatives, new organizational goals, and audits. The specialist will serve as a resource to team members, providing guidance, training, and assistance. Flexibility and adaptability are required due to potential scheduling fluctuations based on interdepartmental and clinical unit communication needs.

Requirements

Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing.
Obtains and subsequently maintains required department specific competencies and certifications.

Nice To Haves

Bachelor's degree in nursing preferred.

Responsibilities

Conduct level of care medical necessity reviews within patient’s medical records.
Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements.
Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable.
Completes activities relating to determination of medical necessity, authorization, continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments.
Workflows may include patient chart review, and assisting with and managing of insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, as well as length of stay.
Ensure validation of appropriate level of care for pre-admission surgical reviews prior to admission.
Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control.
Ability to determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed.
May also be actively involved in collaborating with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes when appropriate.
Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services.
Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization.
Assists the department in monitoring the utilization of resources, risk management and quality of care for patients in accordance with guidelines and criteria.
Assist in report preparation, correspondence, and maintenance of appropriate records.
Ensure services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements.
Maintain working knowledge of payer standards for UM functions for authorization requirements.
May assist with additional special projects related to work, upcoming initiatives, new organizational goals and audits when delegated.
Considered a resource to all team members and acts as a point of contact for guidance, training, and assisting with questions.
Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs within interdepartmental and clinical units are required.