About the position
The role of the Utilization Management (UM) Registered Nurse (RN) is to use clinical expertise by analyzing patient records to determine legitimacy of hospital admission, treatment, and appropriate level of care. The UM RN leverages the algorithmic logic of the XSOLIS Cortex platform, utilizing key clinical data points to assist in status and level of care recommendations. The UM RN is responsible to document findings based on department and regulatory standards. When screening criteria does not align with the physician order or a status conflict is indicated, the UM nurse is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. Additionally, the UM RN is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes.
Responsibilities
- Monitors admissions and performs initial patient reviews within 24 hours of admission; and when warranted by length of stay, utilization review plan, and/or best practice guidelines, on a continuing basis. ,
- Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information. ,
- Maintaining thorough knowledge of payer guidelines, familiarity with payer processes for initiating authorizations, and following through accordingly to prevent loss of reimbursement, including the management of concurrent and pre-bill denials. ,
- Ensuring all benefits, authorization requirements, and collection notes are obtained and clearly documented on accounts in the pursuit of timely reimbursement within established timeframes to avoid denials. ,
- Works collaboratively and maintains active communication with physicians, nursing and other members of the multidisciplinary care team to effect timely, appropriate management of claims. ,
- Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues. ,
- Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. ,
- Collaborates with medical staff, nursing staff, payor, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Communicates with all parties (i.e., staff, physicians, payers, etc.) in a helpful and courteous manner while extending exemplary professionalism. Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. Demonstrates positive interdepartmental communication and cooperation. ,
- Actively participates in clinical performance improvement activities. ,
- Ensures requested clinical information has been communicated as requested. Monitors daily discharge reports to assure all patient stay days are authorized. Follows up with insurance carrier to obtain complete authorization to avoid concurrent or retrospective denials. Communicates with the other departments / team members for resolutions of conflicts between status and authorization. Evaluates clinical review(s) and physician documentation for at-risk claims; performs additional reviews and/or include pertinent addendums to fortify/reinforce basis for accurate claim reimbursement. Demonstrates a strong understanding of medical necessity (i.e., severity of illness, intensity of service, risk), level of acuity, and appropriate plan of care. ,
- Interacts with physicians, physician office personnel, and/or case management departments on an as-needed basis to assure resolution of pending denials, which have been referred to the physician for peer-to-peer review with the Medical Director of the insurance carrier.
Requirements
- Associate of Science degree in Nursing (ASN) ,
- Current and valid license to practice as a Registered Nurse ,
- Minimum three years acute care clinical nursing experience ,
- Minimum two years Utilization Management experience ,
- Excellent interpersonal communication and negotiation skill. ,
- Strong analytical, data management, and computer skills. ,
- Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
Nice-to-haves
- Bachelor of Science in Nursing (BSN) ,
- Clinical experience in acute care facility - greater than five years ,
- Four years Utilization Management within acute care setting ,
- Experience with RAC and appeals ,
- Experience working in electronic health records of at least two years ,
- ACM/CCM certification.
Benefits
- Benefits and Paid Days Off from Day One ,
- Paid Parental Leave ,
- Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense) ,
- Student Loan Repayment Program ,
- Whole Person Well-being and Mental Health Resources