RN Utilization Management - Day Shift

ChristianaCare•Newark, DE

3d•Onsite

About The Position

ChristianaCare Hospital in Newark, DE, is seeking a Utilization Management Nurse (RN) with experience with insurance providers such as Aetna and Cigna, along with a background in an acute care hospital. The RN will work on-site at the Newark Hospital. The primary function is to ensure the delivery of efficient and effective health care while evaluating the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provision of the applicable health benefits plan.

Requirements

DE RN licensure or compact state RN licensure.
Bachelor’s degree in nursing Required.
Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting.
Critical care experience is required.
Minimum 3 years of Utilization Management experience required.
Denial management experience is required.

Nice To Haves

Prior experience working with insurance providers is preferred.
Completes a minimum of 8 continuing education credits (CEU’S) per year in Utilization and/or Case Management.

Responsibilities

Performs admission and concurrent review to identify medical necessity, level of care, and appropriateness of setting using established criteria and clinical guidelines within 24 hours of admission.
Reviews the admission assessment and collaborates with primary nurse and other health care providers to ensure a multidisciplinary plan-of-care is in place to meet identified patient care needs and desired outcomes.
Manages observation level of care and works with the attending physician and/or clinical provider caring for the patient to ensure observation status does not exceed 48 hours.
Identifies system issues that serve as barriers to care.
Participates in the development and implementation of strategies to remove barriers and facilitate performance improvement measures.
Monitors efficiencies in scheduling diagnostic procedures and coordination of treatments to facilitate the achievement of effective clinical, fiscal, quality, and patient satisfaction goals.
Reports information generated from the utilization management referral process for LOS data and physician profile database.
Collaborates with the unit medical director and/or physician advisor to facilitate achievement of clinical, quality, financial, and patient satisfaction goals.
Notifies physician when a patient does not meet criteria for acute care hospitalization and pursues documentation to justify continued stay within 24 hours.
Collaborates with the Physician Advisor to facilitate the achievement of clinical, quality, financial, and patient satisfaction goals.
Presents “Letters of Non-Coverage” (LON) to patients and/or families when the acute stay is no longer necessary (Third Party and/or Medicare).
Communicates and secures continued stay authorization with Managed Care Organizations.
Tracks all carve-outs and submits reason codes for data entry.
Serves as a resource to nursing and ancillary staff, providing education on utilization review processes as needed.
Trends potential barriers to patient advancement through the system intervene assertively and appropriately when necessary.
Provides On-call support for the Transfer Center to evaluate medical necessity and appropriateness when a request is obtained from an outside facility for patient transfer to ChristianaCare.
Identifies the need for the patient to be evaluated by other members of the health care team and takes appropriate action to facilitate.
ED UM works closely with ED providers to review medical necessity and/or collaborate with ED CM for discharge planning, as appropriate.
Actively participates in department operational planning work groups.