PRN Utilization Management Nurse

University Hospitals • Shaker Heights, OH

12h

About The Position

The Utilization Management Nurse collaborates with members of the health care team, patients, and families to coordinate timely and efficient workflows, services, and tasks. The role supports positive patient outcomes and satisfaction, inpatient throughput, appropriate length of stay and level of care, regulatory compliance, continuity and coordination of care, timely authorization, reduced denials, and appropriate reimbursement.

The nurse conducts admission and continued-stay reviews, communicates with internal and external customers, documents review activity and outcomes, and meets department productivity and quality standards. The position also includes other duties as assigned, compliance with policies and standards, and adherence to requirements for maintaining the privacy and security of protected health information.

Requirements

• Graduate of an accredited school of Nursing.
• At least 3 years of acute-care clinical experience.
• At least 2 years of clinical experience with the population to be served.
• Registered Nurse (RN) license in Ohio and/or a Multi State Compact License, required upon hire.
• Sound clinical knowledge of the population to be served.
• Detail-oriented and organized, with analytical and critical-thinking skills and problem-solving ability.
• Ability to work independently and as a team member in a fast-paced environment.
• Strong written and verbal communication skills.
• Ability to use PCs, Microsoft Office, and general office equipment, including printers, copy machines, and fax machines.
• Ability to apply concepts, use sound judgment, and work independently within a framework of guidelines.

Nice To Haves

• Bachelor's degree.
• Additional experience in a sub-acute setting or managed care.
• Experience with InterQual or MCG criteria.
• Knowledge of Medicare, Medicaid, and commercial payer regulations.
• CM certificate.

Responsibilities

• Perform timely and accurate admission and continued-stay reviews in accordance with department policy to support efficient hospital resource use, timely discharge, and appropriate reimbursement.
• Collaborate with the health care team, patients, and families to promote timely communication and completion of workflows and services related to level-of-care decisions and payer decisions about continued stay.
• Document review activity, including application of criteria or policy, clinical reviews submitted to insurance providers, registration changes when appropriate, outcomes, and cost savings, consistent with department requirements.
• Meet department productivity and quality standards.
• Perform other duties as assigned and comply with applicable policies and standards.
• Safely and securely maintain protected health information (PHI), following required training, the UH Code of Conduct, and applicable policies and procedures.

What This Job Offers

• Career Level: Mid Level
• Education Level: No Education Listed