Utilization Management Nurse WP

Advocate Health • Shelby, NC

2d • $36 - $53 • Onsite

About The Position

The Utilization Management Nurse is responsible for coordinating with members of the healthcare team and payors to facilitate the appropriate level of care for patients based on medical necessity. This role promotes open communication between utilization management and the healthcare team regarding the level of care. The nurse is responsible for the timely provision of clinical information to third-party payors to ensure authorization of stay, maintaining compliance with professional standards, national and local coverage determinations, CMS, and state and federal regulatory requirements. They perform admission and continued stay utilization reviews to ensure the medical necessity, appropriate level of care, continued stay, and supportive services, while also examining delays in service provision according to the utilization management plan. The role requires proficiency in applying evidence-based criteria, maintaining timely and appropriate documentation, and utilizing critical thinking skills based on extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation. The nurse will prioritize work for timely and accurate utilization management activities, collaborate to improve quality throughput and care coordination impacting length of stay, minimize costs, and ensure optimum outcomes, while identifying and documenting potentially avoidable delays. Proficiency in using licensed software for daily medical reviews is essential. Effective communication of comprehensive clinical information to third-party payors to secure timely authorization is required, along with providing payor feedback to case managers, social workers, and providers. The nurse will escalate and resolve denials to secure payment, collaborating with payor, physician advisor, attending provider, and the multidisciplinary team to reconcile payor-issued denials. Proficiency and knowledge of various reimbursement criteria, including necessary documentation for regulatory bodies, is also required. The role involves assisting in process improvement initiatives on various committees and supporting the Patient Centered Care Philosophy, recognizing every staff member as a Caregiver. Other duties and responsibilities as assigned will also be performed.

Requirements

• Bachelor’s in Nursing from an accredited school of nursing, required.
• Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works.
• Extensive knowledge of disease processes and clinical outcomes.

Nice To Haves

• Master's degree in business or healthcare related field, preferred.
• Previous utilization review experience preferred.
• 5 years of related nursing experience preferred.
• Clinical experience within the assigned population.
• Case Management experience or background preferred.
• Strong financial and analytical skills preferred.
• Appropriate Professional certification required within 3 years of hire and per Clinical Care Management Certification Guidelines.
• Additional education, training, certifications, or experience may be required within the department by the department leader.

Responsibilities

• Coordination with members of the healthcare team and payors to facilitate placement of patients in the appropriate level of care related to medical necessity.
• Promotes an open communication between utilization management and the health care team concerning level of care.
• Responsible for timely provision/flow of specific clinical information to third-party payors to ensure authorization of stay.
• Maintaining compliance with professional standards, national and local coverage determinations, the Centers for Medicare, and Medicaid Services (CMS) as well as state and federal regulatory requirements, as applicable.
• Performs admission and continued stay utilization reviews to assure the medical necessity of hospital admissions, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services, in accordance with the utilization management plan.
• Demonstrates proficiency in applying nationally accepted evidence-based criteria to assure appropriate hospital level of service.
• Maintains timely and appropriate documentation of all utilization management activities.
• Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
• Prioritize work to facilitate timely accurate utilization management activities for each evidence-based product type.
• Collaborates to improve quality throughput coordination of care impacting length of stay with minimizing cost and ensuring optimum outcomes.
• Identification and documentation of potentially avoidable delays.
• Demonstrates the ability to utilize the licensed software tool to perform and record daily medical reviews.
• Communicates information effectively, including comprehensive clinical information, to third-party payors, to secure timely authorization for the appropriate level of service.
• Provides payor feedback to case managers, social workers, and providers.
• Escalates and resolves denials to secure payment for the necessary care and services provided to the patient.
• Collaborates with payor, physician advisor, attending provider and multi-disciplinary team to reconcile payor-issued denials.
• Demonstrates proficiency and knowledge of various reimbursement criteria, including documentation necessary for reimbursement from regulatory bodies.
• Assist in process improvement of various committees, interdepartmental and departmental as assigned by the VP, AVP, Director, Medical Director, Manager or Team Supervisor.
• Supports and contributes to the Patient Centered Care Philosophy by understanding that every staff member is a Caregiver whose role is to meet the needs of the patient.
• Performs other duties and responsibilities as assigned and within the time frame specified.

Benefits

• Comprehensive suite of Total Rewards
• Benefits and well-being programs
• Competitive compensation
• Generous retirement offerings
• Programs that invest in your career development
• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

What This Job Offers

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