RN Utilization Mgmt Onsite / Utilization Management
About The Position
General Active participation in onsite Barrier teams Responsible for communicating and collaborating with all necessary parties (Physician Advisors, Documentation Excellence Care Coordination, Physician Partners, UM Specialists etc.) and documenting all pertinent information in a timely manner within required hospital systems Knowledge and application of federal, state, HFAP and Quality improvement regulations Responsible for completing clinical review on all assigned patients and communicating the reviews on a timely basis to payors, as directed UM Leadership Track, trend and report payor specific issues escalating to UM Leadership. Collaboration with Physician Advisors regarding ongoing standardized education for our physician & APP partners Participate in design of workflows and procedures to reduce incidence of denials in conjunction with UM Leadership. Delivery of Code 44 notification; change in status to patients or designee, ABN (Advanced Beneficiary Notice), HINN (Hospital-Issued notice of Non-Coverage) and answering questions providing education as needed The Utilization Management Specialist will perform utilization review functions for KHN hospitals Travel required as needed between facilities Other duties as assigned
Requirements
- BSN from an accredited school or Healthcare related BS required
- Requires two years’ experience in utilization management, case management, care coordination, clinical outcomes and/or clinical documentation improvement.
- Five years clinical experience minimum
- Registered Nurse Graduate of accredited RN nursing program with a current unrestricted license to practice in Ohio
Nice To Haves
- Critical care or ED experience preferred.
Responsibilities
- Active participation in onsite Barrier teams
- Communicating and collaborating with all necessary parties (Physician Advisors, Documentation Excellence Care Coordination, Physician Partners, UM Specialists etc.)
- Documenting all pertinent information in a timely manner within required hospital systems
- Knowledge and application of federal, state, HFAP and Quality improvement regulations
- Completing clinical review on all assigned patients and communicating the reviews on a timely basis to payors, as directed
- Track, trend and report payor specific issues escalating to UM Leadership
- Collaboration with Physician Advisors regarding ongoing standardized education for our physician & APP partners
- Participate in design of workflows and procedures to reduce incidence of denials in conjunction with UM Leadership
- Delivery of Code 44 notification; change in status to patients or designee, ABN (Advanced Beneficiary Notice), HINN (Hospital-Issued notice of Non-Coverage) and answering questions providing education as needed
- Perform utilization review functions for KHN hospitals
- Travel required as needed between facilities
- Other duties as assigned
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What This Job Offers
Job Type
Full-time
Number of Employees
5,001-10,000 employees
