RN, Utilization Management

University of Rochester • City of Rochester, NY

2d • $80,923 - $105,208 • Onsite

About The Position

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

This role involves working collaboratively with various departments across the entire health care system to review clinical documentation, utilizing evidence-based criteria to support medical necessity and the appropriate level of patient care for services provided. The position also involves reporting outcome trends and patterns to UM leadership to help identify educational opportunities and performance improvement initiatives across the health care continuum, and adapting to process changes while assisting with education efforts that support ongoing improvement.

Requirements

• Associate's degree in Nursing and 3 years of acute hospital experience required
• NYS Registered Nurse license upon hire required

Nice To Haves

• Bachelor's degree in Nursing (BSN) preferred
• Utilization Management experience preferred
• Database experience including: Interqual, Sharepoint, eRecord, ePARC, Cobius preferred

Responsibilities

• Works collaboratively with various departments across the entire health care system to review clinical documentation, utilizing evidence based criteria to support medical necessity and appropriate level of patient care for services provided.
• Reports outcome trends and patterns to UM leadership to help identify educational opportunities and performance improvement initiatives across the health care continuum.
• Adapts to process changes and assists with education efforts that support ongoing improvement.
• Determines level of care per regulatory requirements.
• Provides level of care notifications to patients and families as needed.
• Works collaboratively with payers to ensure authorization for dates of service.
• Collaborates with HIM, providers, Financial Counseling and Patient Financial Services.
• Monitors all UM hold bills and unplanned readmission reports.
• Conducts initial and concurrent reviews, utilizing evidence based criteria through Interqual.
• Supports discharge appeal process.
• Responsible for departmental denials and appeal activity.
• Documents according to regulatory guidelines and UM RN workflow protocols.
• Conducts clinical documentation improvement efforts through query process.
• Meets productivity expectations established by UM department.
• Provides and supports ongoing educational needs for all UM customers.
• Other duties as assigned.

Benefits

• The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree