Utilization Management Spec RN

MultiCare Health System

2d•$98,336 - $174,826•Onsite

About The Position

The Utilization Management (UM) Specialist Nurse is responsible for concurrent utilization management activities to a defined MHS Licensed Facility. The licensed facility UM Nurse is a link between the patient, health care team, organization leadership, and payers during the patient’s hospital stay. The UM Specialist Nurse facilitates Utilization Review (UR) compliance, and optimal reimbursement through oversight of their assigned licensed facility’s UR process including: accurate admission and continued stay reviews based on CMS regulations, UM criteria, certification and/or authorization, and complete chart documentation. The UM Specialist Nurse serves a resource for Utilization Management clinical and support staff. This position assists with providing guidance on troubleshooting with complex cases and also assists with daily assignments of UM clinical and support staff to ensure patients are patients receiving timely and accurate reviews. This position participates in a collaborative team approach and works independently, as well as cooperatively and collaboratively with health care staff and management. Work situations require specialized knowledge, judgment and skill and this position requires organization and interpretation of information relating to a wide variety of policies, procedures and programs.

Requirements

Bachelor's degree in Nursing, or obtained within five (5) years from the initial date of hire; RN with 15+ years of service may be considered in lieu of education agreement
Current Registered Nurse license in Washington State or Multistate License endorsement (MLS)
Five years of clinical experience required

Nice To Haves

Appeal or denial work experience is highly preferred
Utilization management and/or insurance industry experience preferred
Advanced Degree in Nursing (MSN, PhD, DNP, ARNP) preferred

Responsibilities

Concurrent utilization management activities to a defined MHS Licensed Facility.
Facilitate Utilization Review (UR) compliance and optimal reimbursement through oversight of assigned licensed facility’s UR process.
Ensure accurate admission and continued stay reviews based on CMS regulations, UM criteria, certification and/or authorization, and complete chart documentation.
Serve as a resource for Utilization Management clinical and support staff.
Provide guidance on troubleshooting with complex cases.
Assist with daily assignments of UM clinical and support staff to ensure patients receive timely and accurate reviews.
Participate in a collaborative team approach and work independently, as well as cooperatively and collaboratively with health care staff and management.