RN - Utilization Management Specialist
About The Position
Sanford Health is hiring a registered nurse to conduct level-of-care and medical-necessity reviews in patient medical records. The specialist performs utilization management activities in accordance with the UM plan and accreditation and regulatory requirements, and supports implementation, evaluation, and improvement of utilization management and prior authorization processes. The role includes medical-necessity determinations, authorizations, continued-stay reviews, and diagnosis and procedural coding for working diagnosis-related group (DRG) assignments. Workflows may include patient chart review; insurance coverage and denial management; prior authorizations; scheduled procedures; same-day readmission reviews; and length-of-stay reviews. The specialist validates the appropriate level of care for pre-admission surgical reviews and uses InterQual clinical decision-support criteria to assess service appropriateness and cost control. The position collaborates with physicians and other clinical professionals on resource utilization, fiscal outcomes, and documentation improvement; educates healthcare team members about utilization trends, regulations, and policies; and helps monitor resource use, risk management, and quality of care. Additional duties include preparing reports and correspondence, maintaining records, supporting special projects and audits, and providing guidance and training to team members. Scheduling may fluctuate to meet interdepartmental and clinical-unit communication needs. The schedule is Monday through Friday, eight-hour day shifts, with a Saturday weekend rotation every 7–8 weeks. Training is onsite, with consideration of remote work after 6 months to 1 year. The position is 40 hours per week, non-union, and has a stated salary range of $28.50–$38.50.
Requirements
- Graduate from a nationally accredited nursing program, including CCNE, ACEN, or NLN CNEA accreditation.
- Hold an unencumbered registered nurse (RN) license with the State Board of Nursing.
- Obtain and maintain required department-specific competencies and certifications.
Nice To Haves
- Bachelor's degree in nursing preferred.
Responsibilities
- Conduct level-of-care and medical-necessity reviews of patient medical records.
- Perform utilization management activities in accordance with the UM plan and applicable accreditation and regulatory requirements.
- Complete or coordinate implementation, evaluation, and improvement of utilization management and prior authorization processes.
- Perform medical-necessity determinations, authorizations, and continued-stay reviews, including diagnosis and procedural coding for working DRG assignments.
- Review patient charts and assist with insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmissions, and length of stay.
- Validate the appropriate level of care for pre-admission surgical reviews.
- Use InterQual clinical decision-support criteria to assess medical-service appropriateness and support cost control.
- Refer cases that do not meet departmental standards for secondary review or escalation as appropriate.
- Collaborate with healthcare team members to promote medically necessary resource utilization and fiscal outcomes when appropriate.
- Work with physicians and other clinical professionals on documentation improvement for effective and appropriate services.
- Educate healthcare team members about utilization trends, external regulations, and internal policies affecting resource utilization and prior authorization.
- Assist in monitoring resource utilization, risk management, and quality of care in accordance with applicable guidelines and criteria.
- Prepare reports and correspondence and maintain appropriate records.
- Ensure services comply with professional standards, NCD/LCD, CMS, and state and federal regulatory requirements.
- Maintain working knowledge of payer utilization-management standards and authorization requirements.
- Assist with delegated special projects, initiatives, organizational goals, and audits.
- Provide guidance, training, and answers to questions as a resource and point of contact for team members.
- Adapt scheduling as needed to meet communication needs across interdepartmental and clinical units.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
