RN, Utilization Management

University of Rochester•City of Rochester, NY

1d•$81,307 - $109,761•Onsite

About The Position

The University of Rochester is seeking an RN for their Utilization Management department. This full-time position involves collaborating with various departments across the health care system to review clinical documentation, ensuring medical necessity and appropriate patient care levels using evidence-based criteria. The role also involves reporting outcome trends, adapting to process changes, and assisting with educational efforts to drive continuous improvement within the healthcare continuum.

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.