Utilization Management Nurse (RN)

Saint Francis Health System

1d • Onsite

About The Position

Provides administrative and clinical support to the hospital and treatment teams throughout the review of patients including, but not limited to their placement in various levels of care and receipt of necessary services. The Utilization Management (UM) Registered Nurse will communicate with providers the details of reimbursement issues and participate in treatment teams, Patient Care Committee, and the Utilization Review Staff Committee by providing data and contributing to the improvement of internal processes.

Requirements

• Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom or Master's degree in Nursing.
• Valid multi-state or State of Oklahoma Registered Nurse License.
• Minimum 2 years of related experience in an acute care setting.
• Ability to organize and prioritize work in an effective and efficient manner.
• Effective interpersonal, written, and oral communication skills.
• Demonstrated ability to integrate the analysis of data to discover facts or develop knowledge, concepts, or interpretations.
• Ability to be detail oriented as required in the examination of numerical data.
• Ability to synthesize clinical case data into concise summaries.
• Working knowledge of Microsoft Word, Excel and Access in the preparation of correspondence and reports.

Responsibilities

• Gathers, prepares and supplies required clinical/treatment information needed to obtain authorization within the review interval(s) time requirements.
• Participates in treatment team and/or Patient Care Committee by providing information about eligibility, benefits, and criteria for the selected level of care.
• Assists in discharge planning, as needed.
• Identifies QI Triggers for individual patient situations, reporting them promptly to the UM Manager, appropriate clinicians and Process Improvement/Quality Director.
• Reviews eligibility and benefits of patients to validate accurate level of care utilization.
• Investigates and prepares appeals for insurance companies when denial of reimbursement is related to medical necessity or to other treatment issues.
• Participates in quality-of-care and UM process improvement on an ongoing basis and assists with development of the UR Staff Committee's process improvement goals.
• Provides staff education to further the goals of UR.

What This Job Offers

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