Registered Nurse Utilization Management Specialist

* Area of Interest: Nursing

• FTE/Hours per pay period: 0.4
• Department: Utilization Management
• Shift: Weekends( Sat/Sun) 0730-1600
• Job ID: 177255

Overview reputed company is seeking an RN Utilization Management Specialist to join reputed company! Under the direction of the Manager of Utilization Management, the RN Utilization Management Specialist serves a key role in coordinating the organization's interdisciplinary effort to assess and promote appropriate utilization of health care resources, provision of high-quality health care, optimal clinical outcomes, and patient and provider satisfaction. The RN UM Specialist will work to track and minimize the inappropriate use of such resources, provides the Utilization Management function for patients admitted to UPH, and facilitates effective utilization of resources through ongoing interactions with physicians, third party payers and regulatory agencies. Location: Remote - applicants must reside reputed company the UPH footprint of Iowa, Illinois, or Wisconsin Hours: Weekend day shift: Saturdays and Sundays, 7am-4pm Why reputed company? At reputed company, you matter. We're proud to be recognized as a Top 150 reputed company to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to reputed company members. Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you're in. Here are just a few:

• Expect paid time off, parental leave, 401K matching and an employee recognition program.
• Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.
• Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.

With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together. And, we reputed company equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. Find a fulfilling career and reputed company a difference with reputed company.

Responsibilities

• Performs utilization management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources.
• Maximizes positive financial outcomes for patients and hospital by conducting timely initial and ongoing reputed company chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care.
• Applies utilization criteria using designated software to complete documentation reputed company to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making.
• Requests secondary reviews with physician advisors as appropriate, if admission or reputed company stay criteria are not met, assuring appropriate and timely level of care status.
• Assesses patient status, including reviewing outpatient surgical and observation admissions for the appropriate level of care, and continuously monitors length of stay for appropriate and timely medical management.
• Applies accepted potentially avoidable day logic to reviews for accurate and timely data collection.
• Proactively monitors insurance approval status in partnership with the UM Administrative Coordinator.
• Provides education to staff and physicians regarding medical necessity, levels of care and appropriate utilization of resources as needed.
• Pursues denials at the affiliate level in a timely manner to secure payment of services.
• Serves as a resource to internal and external staff, providers, payers, and patients on issues reputed company to utilization management.
• Maintains reputed company knowledge of Utilization Review Methodology, software, criteria, and regulations governing various payment systems.
• Maintains reputed company knowledge of the UPH Utilization Management Plan.
• Maintains reputed company knowledge of CMS rules (e.g., Code 44, A - B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement.
• Coordinates and monitors appeals with internal and external physician advisors for Second Level Review as needed.
• Provides education to patients and families regarding the role of the Utilization Management Specialist and provides clarification reputed company needed on level of care and their payer reputed company regulatory requirements - as needed.

Qualifications

• Registered Nurse - licensed in Iowa. Will need to obtain RN in Illinois (proivded by UPH)
• Associates Degree or Diploma (RN) in Nursing required
• 2 years of nursing experience

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