RN - Utilization Management Analyst - PRN
About The Position
MU Health Care is seeking a Utilization Management Analyst RN to oversee patient admissions, conduct utilization reviews, and ensure care is medically necessary and efficient. The role supports appropriate reimbursement for hospital services while advocating for patients and educating staff and physicians about utilization issues. It requires strong communication and collaboration with healthcare teams and an understanding of government and private insurance payer guidelines. The position is PRN, with a stated schedule of Monday through Friday, 7 a.m. to 3 p.m., and possible occasional weekend coverage. It is hybrid and based at either the Quarterdeck Building in Columbia, Missouri, or Capital Region Medical Center in Jefferson City, Missouri. Compensation is $36.11 per hour.
Requirements
- Missouri Board of Nursing RN license or Nurse Licensure Compact multistate RN license. Compact-state RNs must apply under their new state of residency within 30 days after their primary state of residency changes.
- 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 the application of InterQual and/or Milliman Criteria.
Nice To Haves
- Experience in tertiary care and/or a 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 for appropriate conversion to inpatient status or discharge.
- Assist with denials and appeals, and document avoidable delays and days.
- Monitor patients with extended lengths of stay and develop plans of action when stays exceed benefit-plan allowances.
- Monitor admissions according to third-party criteria and perform retrospective reviews as needed.
- Collaborate with payer reviewers to support appropriate resource utilization.
- 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 resource utilization.
- 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; escalate payer issues to attending physicians and hospital leadership.
- Collaborate with the healthcare team to support the course of care delivery and timely discharge; serve as a liaison between payers and physicians.
- Apply medical discernment and critical thinking on a case-by-case basis to maximize reimbursement.
- Participate in formal education about payer criteria and policies for medical students and residents.
- Complete unit- or department-specific duties and expectations as outlined in department documents.
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What This Job Offers
Career Level
Mid Level
Education Level
No Education Listed
