Utilization Management Nurse Jobs

About The Position

Requirements

• Graduate of an accredited school of Nursing
• 3+ years of clinical experience (acute care)
• 1+ years of experience in utilization management/case management in an acute care setting
• Must have sound clinical knowledge base of the population to be served
• Detail-oriented and organized, with good analytical and problem solving ability
• Notable client service, communication, presentation and relationship building skills
• Ability to function independently and as a team player in a fast-paced environment
• Strong written and verbal communication skills
• Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.)
• Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines
• Registered Nurse (RN), Ohio and/or Multi State Compact License Upon Hire

Nice To Haves

• Bachelor's Degree
• Experience as an ED nurse
• Experience in ED utilization management/case management
• Experience with Interqual or Milliman criteria
• Knowledge of Medicare, Medicaid and commercial payer regulations
• CM software proficient
• CM certificate

Responsibilities

• Cover shifts to assist with coverage of PT and FT nurses taking PTO, typical shift is 10P-10A
• Manage recommendation of patients being admitted to the hospital setting using criteria set (MCG and IQ)
• Collaborate and coordinate with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks
• Support positive patient health care outcomes
• Increase patient/health care team outcomes and satisfaction
• Improve inpatient throughput and appropriate length of stay
• Improve communication, awareness and adherence to regulatory requirements associated with utilization
• Support for inappropriate level of care and decreased inpatient bed day denials
• Ensure continuity and coordination of care
• Ensure appropriate and timely authorization for level of care
• Decrease denials
• Ensure appropriate reimbursement
• Perform and document timely and accurate concurrent review of records and discuss plan of care with ED physicians to support the decision making process with regard to LOC decisions inpatient admission or outpatient observation services
• Support effective and timely communication of the physician decision regarding inpatient admission or outpatient observation services for accurate registration status, and delivery of appropriate notices to patient when required
• Conduct all CM activities with a focus on continuous quality improvement in a manner that is supportive of UHC quality initiatives and in compliance with applicable regulatory requirements
• Perform other duties as assigned
• Comply with all policies and standards
• Abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients