UTILIZATION MANAGEMENT RN
Serves as the interdisciplinary team expert and consultant regarding appropriate classification determinations. Ensures adherence to medical necessity criteria, regulatory requirements, and insurance rules. Acts as the primary denials prevention agent by performing admission and continued stay reviews as per government and commercial payor contractual requirements, to include the JCAHO Utilization Review Standard. Responsible for timely provision and flow of clinical information to and from third party payors and Care Management staff to ensure authorization of hospital services. Collaborates with the healthcare team, as well as Compliance and Revenue Cycle partners, on issues related to: continued stay, avoidable days, readmissions, RAC denials, second level reviews, outlier issues, and denials management. Serves as a contributing member of the Utilization Management Committee.
Education:Academic degree in nursing (BSN or higher) required within 5 years of hire or by December 31, 2020, whichever is earlier. Any exception to the BSN requirement by December 31, 2020 for current incumbents will need approval of the Nurse Executive Committee.
Experience:This position requires extensive knowledge of diseases, procedures, treatments, prognosis, medical necessity requirements and healthcare reimbursement. Minimum 2 years of acute care nursing required. Relevant experience in one or more of the following areas preferred:
Care coordination of diverse patient populations
Knowledge of levels of care throughout the health care continuum
Denials prevention and management
Licensure/Certification:Current applicable state RN licensure required. Certification preferred, and required within 3 years of hire/transfer into this job if hired on/after June 1, 2014, in at least one of the following:
Certified Professional in Healthcare Management (CPHM)
InterQual Certified Instructor (IQCI)
Health Care Quality and Management (HCQM)
Certified Case Manager (CCM)
Accredited Case Manager (ACM)
Certification for current incumbents required by June 1, 2017.
Excellent organization, oral and written communication skills for effective interaction with patients, physicians, health care team members and representatives from insurance plans.
Proficient statistical analytical skills for application of medical necessity criteria to patient stays and review of trends within healthcare.
Knowledge of transition planning, health care reimbursement and utilization management processes.
Knowledge of specific criteria and CMS guidelines for authorizations of continued inpatient stay or provision of outpatient services.
Knowledge of regulatory issues. Ability to adhere to and implement regulations in an effective manner. Serve as a resource to all team members regarding regulatory issues.
Keyboard skills and ability to navigate electronic systems applicable to job functions.
PREFERRED EMPLOYEE PROFILE
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