Utilization Management Nurse WP

Advocate Health and Hospitals Corporation•Cleveland, NC

1d•Hybrid

About The Position

This part-time Utilization Management Nurse position is responsible for coordinating with healthcare teams and payors to ensure patients are placed in the appropriate level of care based on medical necessity. The role involves promoting open communication, facilitating the flow of clinical information for authorizations, and maintaining compliance with professional standards and regulatory requirements. The nurse will perform admission and continued stay reviews, apply evidence-based criteria, and maintain documentation of all utilization management activities. Critical thinking skills, knowledge of disease processes, and prioritization are essential for timely and accurate reviews. The position also involves collaborating to improve care coordination, identify avoidable delays, and utilize licensed software for medical reviews. Effective communication with third-party payors, providing feedback to case managers and providers, and escalating/resolving denials are key responsibilities. The role also includes assisting in process improvement initiatives and supporting the Patient Centered Care Philosophy.

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.
Must speak English fluently and write English in understandable terms.

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