Utilization Management RN
About The Position
Under general direction: The Utilization Management RN serves as a leader resource in the Utilization Management process. They collaborate with physicians and other members of the healthcare team to promote and adhere to regulatory compliance. The UM RN conducts initial concurrent and retrospective medical necessity reviews. All Utilization Management activities are performed in accordance with the mission vision and values of UVA Medical Center. Analyze and evaluate complex medical documentation: Demonstrates competence in interpretation of clinical data, and the application of UM tools. Collaborates with physicians and care team: Attending, resident, mid level practitioners. Utilizes judgement and critical thinking in determining what cases to refer for second level review to external physician consultants and internal UVA UR MD’s. Provides complete accurate and timely clinical data to Insurance companies. Utilizes judgement and critical thinking to determine if denied cases will be appealed utilizing medical, contract and payor rules. Conducts appeals with external entities and Consultants. Manages appealed cases including external review and resolution for Billing. Actively supports the financial mission of the department. Practices according to department standards. Assumes responsibility for professional development of self and contributes to and assists with the professional development of others. Demonstrates leadership in the UM role. In addition to the above job responsibilities, other duties may be assigned.
Requirements
- Education: Bachelor of Science in Nursing from accredited nursing program.
- Experience: 2 years acute care hospital experience.
- Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia required.
Responsibilities
- Analyze and evaluate complex medical documentation
- Demonstrates competence in interpretation of clinical data, and the application of UM tools.
- Collaborates with physicians and care team: Attending, resident, mid level practitioners.
- Utilizes judgement and critical thinking in determining what cases to refer for second level review to external physician consultants and internal UVA UR MD’s.
- Provides complete accurate and timely clinical data to Insurance companies.
- Utilizes judgement and critical thinking to determine if denied cases will be appealed utilizing medical, contract and payor rules.
- Conducts appeals with external entities and Consultants.
- Manages appealed cases including external review and resolution for Billing.
- Actively supports the financial mission of the department.
- Practices according to department standards.
- Assumes responsibility for professional development of self and contributes to and assists with the professional development of others.
- Demonstrates leadership in the UM role.
Benefits
- Comprehensive Benefits Package: Medical, Dental, and Vision Insurance
- Paid Time Off, Long-term and Short-term Disability, Retirement Savings
- Health Saving Plans, and Flexible Spending Accounts
- Certification and education support
- Generous Paid Time Off
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
1-10 employees
