Utilization Management Nurse II

Medical University of South Carolina

23h • Onsite

About The Position

Conducts utilization reviews to determine if patients are receiving care appropriate to the severity of illness or condition and intensity of services required. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Consults with providers and other stakeholders as needed. The Utilization Management Nurse (UMN) reports to the Manager of Case Management and Care Transitions. Under general guidance of the Nurse Case Manager Team Leader of the Service Line, the UM Nurse functions as a member of the clinical service line team facilitates optimal reimbursement through accurate certification of their assigned patients. This position conducts initial admission reviews and refers cases for secondary review when appropriate. This role ensures the adherence to regulatory requirements with Medicare, FFS Medicaid, and other government payers. The UM Nurse refers and consults with the multidisciplinary team to promote appropriate communication of the review results to hospital revenue professionals to ensure proper utilization of hospital resources for accurate reimbursement.

Requirements

• Bachelor's degree in Nursing from an accredited school of nursing
• Five years of nursing work experience to include two years utilization / case management experience in a hospital setting required.
• Evidence of committee involvement within a healthcare setting needed (either departmental or hospital-wide).
• Must possess excellent verbal and written communication skills.
• Licensure as a registered nurse by the state of South Carolina or compact state required.
• Ability to perform job junctions while standing (C), while sitting (I), while walking (F).
• Ability to climb stairs (I); work indoors (C); work from elevated areas (I); work in confined/cramped spaces (I); perform job functions from kneeling positions (I); bend at the waist (F); twist at the waist (F); squat and perform job functions(I); perform ‘pinching’ operations (I); and fully use both hands/arms (C).
• Ability to perform repetitive motions with hands/wrists/elbows and shoulders (F), ability to fully use both legs (C), to reach in all directions, possess good finger dexterity (C), maintain tactile sensory functions (C) and maintain good olfactory sensory function (C).
• Ability to lift and carry up to 50 lbs, unassisted and lift/carry patients up to 350 lbs (+/-), assisted.
• Ability to lift objects from floor level to height of 36 inches, up to 50 lbs, unassisted.
• Ability to lower objects, to 50 lbs, from height of 36 inches, unassisted.
• Ability to push/pull objects up to 350 lbs (+/-), unassisted.
• Maintain 20/40 vision, corrected. (C), see and recognize objects close at hand (C) and objects at a distance (C).
• Ability to match or discriminate between colors (C), to determine distance/relationship between objects; depth perception. (C) and good peripheral vision capabilities (C).
• Ability to maintain hearing acuity, with correction (C), ability to hear and understand whispered conversations at a distance of three feet, must be ambidextrous.
• Ability to perform gross motor functions with frequent fine motor movements (C).
• Ability to be qualified physically (by medical personnel) for respirator use, initially and annually.
• Ability to deal effectively with stressful situations.
• Computer literacy
• Ability to work rotating shifts
• Provide extended leadership coverage as needed
• Ability to learn and use new processes, tools equipment as required.

Nice To Haves

• Prior leadership experience preferred.
• Familiarity with InterQual and/or MCG screening criteria desired.

Responsibilities

• Conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition.
• Monitors patient charts and records to evaluate care concurrent with the patients treatment.
• Reviews treatment plans and status of approvals from insurers.
• Collects and complies data as required and according to applicable policies and regulations.
• Consults with providers and other stakeholders as needed.
• Conducts initial admission reviews and refers cases for secondary review when appropriate.
• Ensures the adherence to regulatory requirements with Medicare, FFS Medicaid, and other government payers.
• Refers and consults with the multidisciplinary team to promote appropriate communication of the review results to hospital revenue professionals to ensure proper utilization of hospital resources for accurate reimbursement.

Benefits

• Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level