RN - Utilization Management

Guthrie Enterprise•Binghamton, NY

15h

About The Position

The Registered Nurse (RN) Utilization Management (UM) in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, payers, and the Guthrie Clinic health system business office, is responsible for developing, coordinating, and maintenance of UM processes based on regulatory and reimbursement requirements of commercial and government payers. The UM RN responsibilities include performing a variety of concurrent and retrospective UM-related clinical reviews and revenue cycle functions ensuring appropriate status and corresponding reimbursement. The UM RN leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. The UM RN maintains current knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to UM. This role is responsible for ensuring that the UM program maintains documented, up-to-date policies and procedures and ensures that all UM key processes have valid outcome measures that are monitored for compliance and reported to a variety of audiences. The UM RN effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment. The UM RN is a member of and provides support to the hospital’s UM Committee. He/she collaborates with multiple leaders at various levels throughout the Guthrie Clinic health system, including directors and vice presidents, for the purpose of supporting and improving the UM program.

Requirements

Current RN licensure required for the state in which the employee works.
BSN with a minimum of five years’ clinical experience in an acute health care setting preferred.
RN with a minimum of five (5) years relevant acute care, clinical experience willing to pursue and complete a BSN may be considered.
Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames.
Knowledge of health benefit plans and related UM requirements preferred.
Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes preferred.
Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable

Nice To Haves

BSN with a minimum of five years’ clinical experience in an acute health care setting
Knowledge of health benefit plans and related UM requirements
Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes
Knowledge of computer applications (such as Microsoft word processing and spreadsheets)

Responsibilities

Coordinate and facilitate correct identification of patient status.
Collaborate and set standards with registered nurse (RN) case managers (CMs) and outcome managers to ensure that all hospitalized patients have the correct admission status (inpatient, outpatient short procedure, etc.).
Complete short stay work queue reviews and track and trend results for reporting and education purposes.
Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.
Maintain status determination tools and other UM tools and distribute to staff as needed.
Coordinate and integrate UM functions.
Prepare succinct, written clinical case summaries that include rationale for the recommended billing status.
Serve as a resource person for RN CMs and others to ensure consistent and accurate patient status determinations for appropriate claim submission.
Participate in UR Committee and UM activities.
Assist with preparation of discussion and appeal letters for Medicare/Medicaid medical necessity denials.
Assist with developing and maintaining efficient and effective documented policies and procedures for non-coverage notifications, including Notice of Non-coverage (HINN) and Advance Beneficiary Notice of Noncoverage (ABN), to include compliance monitoring.
Collaborate with all members of the healthcare team, both internal and external customers.
Provide clinical consultation regarding UM to providers and other colleagues.
Respond to all payers, billing office, and business office requests appropriately, accurately, and timely.
Interact with providers, payers, nurses, and other hospital colleagues as indicated related to UM activities.
Participate in clinical performance improvement activities to achieve organizational goals.
Use data to drive performance improvement strategies and action plans related to UM.
Create reports, displaying data and providing narrative analysis to a variety of audiences.
Participate in development, implementation, teaching, evaluation and revision of UM standards.
Demonstrate positive and professional written, verbal, and nonverbal communication skills.
Effectively and efficiently create clinical case summaries from medical record documentation for internal and external audiences, including commercial payers and government payers/contractors.
Effectively promote conflict resolution with constructive solutions.
Reflect concise clinical pertinence in documentation for assigned patient population.
Respond to all inquiries related to UM within a professional manner.
Document and escalate UM quality and clinical care risks concerns (as identified during clinical reviews) and refer to the appropriate department for follow-up.
Apply advanced critical thinking and conflict resolution.
Demonstrate a working knowledge of regulatory and survey standards (Medicare, Medicaid, Joint Commission) pertinent to UM.
Demonstrate a working knowledge of disease and age specific impact.
Demonstrate a working knowledge of approved status determination criteria and apply consistently according to inter-rater reliability techniques.
Demonstrate a working knowledge of Guthrie Health System process improvement.
Facilitate review of rejected medical claims using clinical evidenced based tools and peer-reviewed journals.
Provides clinical denial management assistance to Physician Advisor and denials team.
Ensure compliance with all federal, state, and local regulations governing rendered patient services and reimbursement.
Reviews and analyzes current audit information to facilitate UM process performance improvement and interdisciplinary healthcare and business/finance teams.
Responds to all internal and external requests for information, data, and /or education specific to clinical denials management.
Collaborates with revenue cycle team (business, billing, etc.) Admissions, coding, and the clinical team to answer clinical questions specific to denial management.
Seeks consultation from appropriate discipline/department as needed to expedite clinical review of potential and actual denials.
Provide ongoing education to providers, CM, billing, and business office teams as related to UM, medical necessity, patient status, InterQual, non-coverage notifications, and other UM areas as indicated.
Participate in new department staff orientation specific to UM and patient status.
Develop and provide individualized UM-related education as needed.
It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.