RN-Utilization Management and Denials Liaison

It's more than a career, it's a calling.

Worker Type:

Job Summary:

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES 

• Serves as the direct resource for the regional physician liaisons regarding Utilization Management (UM) initiatives and regional specific UM issues.  
• Performs audits on UM denial write off accounts to ensure accurate categorizing of the root cause of denial and to identify potential opportunities for claims re-bill. 
• Collaborates with Managed Care Organization (MCO) team members to stay abreast of contractual updates to develop and maintain UM payer grids with contractual requirements. 
• Serves as a UM subject matter expert on state and federal regulatory requirements related to UM processes. 
• Represents the system UM team on committees and work groups as assigned by leadership.  
• Presents critical messages and complex information and reports to UM leadership. 
• Provides responses to questions and concerns raised by physician liaisons, clinical and operational team members, providers, and UM leaders. 
• Supports UM leadership and collaborating teams and providers with resources, data, and education to improve UM outcomes.  
• Applies the existing body of evidence-based practice and scientific knowledge in health care to medical-surgical nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service. 
• Performs other duties as assigned. 

EDUCATION

• Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

• Two years' acute nursing experience, four years of Utilization Management experience 

PHYSICAL REQUIREMENTS

Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
Frequent keyboard use/data entry.
Occasional bending, stooping, kneeling, squatting, twisting and gripping.
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 
 
State of Work Location: Illinois 

•     Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) 

     
State of Work Location: Missouri 

•     Registered Nurse (RN) Issued by Compact State  
•     Or 
•     Registered Nurse (RN) - Missouri Division of Professional Registration 

 
State of Work Location: Oklahoma 

•     Registered Nurse (RN) Issued by Compact State  
•     Or 
•     Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) 

     
State of Work Location: Wisconsin 

•     Registered Nurse (RN) Issued by Compact State  
•     Or 
•     Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Work Shift:

Department:

Scheduled Weekly Hours:

Benefits:

SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.

• Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE). 

• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.

• Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members. 

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SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.