RN - Utilization Management Analyst Nurse
About The Position
MU Health Care is seeking a Registered Nurse to oversee patient admissions and utilization reviews, ensuring care is medically necessary and efficient while supporting appropriate reimbursement. The role involves applying government and private payer guidelines, advocating for patients, and educating staff and physicians about utilization issues. The position is part of the Utilization Management Department and is hybrid, with on-site work required approximately once per month at either the Quarterdeck Building in Columbia, Missouri, or Capital Region Medical Center in Jefferson City, Missouri. The schedule is four 10-hour shifts, including Saturday and Sunday, from 7:00 a.m. to 5:00 p.m. The posted annual base pay range is $68,265–$100,401, based on experience.
Requirements
- Missouri Board of Nursing RN license or Nurse Licensure Compact multistate RN license. If the primary state of residence changes, compact-state RNs must apply under the new state of residence within 30 days.
- Two years of hospital clinical experience or two years of current utilization review experience.
- Excellent written and verbal communication skills.
- Knowledge of government and private insurance payer guidelines and regulations.
- Knowledge of applying InterQual and/or Milliman Criteria.
Nice To Haves
- Experience in a tertiary-care and/or teaching hospital.
- Experience in conflict resolution is strongly desired.
- Additional license or certification requirements as determined by the hiring department.
Responsibilities
- Monitor unscheduled admissions for appropriate patient type, timely payer notification, and appropriate target length of stay.
- Complete pre-certification and preauthorization processes as assigned.
- Monitor 23-hour observation cases and ensure conversion to inpatient status when appropriate or discharge.
- Assist with denials and appeals, and document avoidable delays and days.
- Monitor patients whose length of stay exceeds benefit-plan allowances and develop plans of action.
- Review admissions against third-party criteria and perform retrospective reviews as necessary.
- Collaborate with payer reviewers to support appropriate utilization of resources.
- Provide formal and informal education and in-services to staff and physicians on utilization issues.
- Assist with developing and revising policies, procedures, and service standards.
- Participate in utilization-management improvement efforts and assigned continuous quality improvement activities.
- Maintain current knowledge of payer criteria and policies related to utilization of resources.
- Audit charts at the request of Patient Accounts and Revenue Recovery, and compile data and statistics for monthly and annual reporting.
- Maintain clinical expertise in medical-surgical, pediatric, and psychiatric care, and escalate payer issues to attending physicians and hospital leadership.
- Collaborate with the healthcare team to support timely discharge and serve as a liaison between payers and physicians.
- Apply medical discernment and critical thinking case by case to maximize reimbursement.
- Participate in formal education on payer criteria and policies for medical students and residents.
- Complete unit- or department-specific duties and expectations as outlined in department documents.
Benefits
- Health, vision, and dental insurance coverage starting on day one.
- Generous paid leave and paid time off, including ten holidays.
- Multiple retirement options, including 100% matching up to 8% and full vesting in three years.
- Tuition assistance for employees (75%) and immediate family members (50%).
- Discounts on cell phone plans, rental cars, gyms, hotels, and more.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
