Utilization Management Specialist

Logan Health

4d • Remote

About The Position

Bring Your Clinical Expertise to Logan Health’s Utilization Management Team! Our Mission: Quality, compassionate care for all. Our Vision: Reimagine health care through connection, service and innovation. Our Core Values: Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence. Logan Health is searching for a fully remote Utilization Management Specialist to join our dedicated team! Our Utilization Management Specialists play a vital role in reviewing admissions across the Logan Health system to determine appropriate admission status. This position is ideal for an RN or Social Worker with strong acute care (hospital) experience, exceptional communication skills, and the confidence to collaborate with physicians, case management, and insurance partners. You’ll make a direct impact on patient outcomes and resource management while working in a supportive, mission-driven environment. What we offer you! Four day work week! Affordable Medical Benefits package 401(k) with generous immediate employer match Logan Health Fitness Center Membership Discount! A supportive, mission-driven nursing culture focused on quality, compassion and person-centered care! Position/schedule highlights: Fully remote opportunity available only to Montana residents (candidates located outside of Montana will not be considered) Full-time, four 10-hour shifts per week Every third weekend (Saturday & Sunday) rotation Variable shifts - Morning shifts typically start around 7 a.m.; afternoon shifts begin around 10 a.m. Here's some of what you'll be doing: Review all daily inpatient and observation admissions across the Logan Health system Evaluate physician documentation and patient data to determine appropriate admission status Reassess patients throughout their stay to ensure continued criteria for level of care are met Collaborate with the physician UM Advisor, case management team, and insurance partners to facilitate authorizations and medical necessity reviews Assist with scheduling and coordinating peer-to-peer physician reviews Communicate with providers, nurses, and other stakeholders to ensure accurate documentation and smooth care transitions Identify and address any issues that could delay reviews or affect compliance Utilize electronic medical records efficiently to support documentation, review, and reporting Work independently while maintaining strong collaboration within the interdisciplinary team Who you are: You’re detail-oriented, confident in your clinical judgment, and comfortable managing multiple priorities in a fast-paced environment. You bring experience in acute care and understand how to interpret documentation and regulations accurately. Strong computer literacy, analytical thinking, and professional communication are essential for success in this role. Don't miss this rare opportunity to be part of a team making a real impact!

Requirements

• Minimum of one (1) of the following required: Current Montana RN License or a multi state compact license with authorization to practice nursing within the state of Montana Bachelor’s or Master's degree in Social Work
• For RN applicants - Associate’s degree required. Bachelor’s degree preferred.
• Minimum of five (5) years’ acute care hospital experience required.
• Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
• Excellent verbal and written communication skills including the ability to communicate effectively with various audiences

Nice To Haves

• Prior experience as an inpatient utilization review nurse or UM specialist preferred.
• Knowledge in areas of: Medicare and Medicaid UM regulations, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management preferred.

Responsibilities

• Review all daily inpatient and observation admissions across the Logan Health system
• Evaluate physician documentation and patient data to determine appropriate admission status
• Reassess patients throughout their stay to ensure continued criteria for level of care are met
• Collaborate with the physician UM Advisor, case management team, and insurance partners to facilitate authorizations and medical necessity reviews
• Assist with scheduling and coordinating peer-to-peer physician reviews
• Communicate with providers, nurses, and other stakeholders to ensure accurate documentation and smooth care transitions
• Identify and address any issues that could delay reviews or affect compliance
• Utilize electronic medical records efficiently to support documentation, review, and reporting
• Work independently while maintaining strong collaboration within the interdisciplinary team
• Coordinates and facilitates correct identification of patient status.
• Utilizes a validated criteria set and ensures hospitalized patients have the correct admission status.
• Completes short stay work queue reviews and tracks and trends results for reporting and education purposes.
• Identifies opportunities for process and system improvement and initiates and leads performance initiatives as indicated.
• Identifies and facilitates resolution of system process issues impeding UM functions.
• Identifies and resolves delays and obstacles as appropriate.
• Collaborates with appropriate stakeholders to answer clinical questions related to medical necessity and patient status.
• Performs concurrent and retrospective reviews as directed by assigned leadership.
• Assists with preparation of appeal letters for insurance denials, audit activities, and responds to payer inquiries in a professional manner.
• Interacts with appropriate stakeholders in a timely, positive manner to resolve UM and patient status issues.
• Seeks consultation from appropriate disciplines and/or departments as required to expedite care and facilitate timely and accurate documentation of patient status and clinical reviews.
• Refers UM issues to assigned leadership and/or appropriate stakeholder(s) in a timely manner and monitors until it is resolved.
• Participates in development, implementation, teaching, evaluation, and revision of departmental standards related to UM.
• Participate in the orientation of new department staff specific to UM.
• Documents UM, quality and risk concerns and refers to appropriate departments as applicable for follow up.

Benefits

• Four day work week!
• Affordable Medical Benefits package
• 401(k) with generous immediate employer match
• Logan Health Fitness Center Membership Discount!
• A supportive, mission-driven nursing culture focused on quality, compassion and person-centered care!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 51-100 employees