RN -Utilization Management /Clinical Denial Management

Overview

Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of the Carle Foundation Hospital. Facilitates the care of patient by insuring that admissions and continued days are medically necessary, cost-effective, and provided in the appropriate level of care to qualify for reimbursement.

Responsibilities

• The UM staff RN will function within the IP Care Coordination Department to ensure that the most cost-effective and appropriate use of health care services for patients treated by Carle Foundation Hospital.
• Ensures efficient patient flow and throughput
• Initial assessment of all new patients for correct status (admission/observation/outpatient) based on UR medical necessity criteria.
• Performs concurrent reviews of all patient charts to ensure proper resource utilization as necessary to identify practice trends.
• Keeping LOS within patients working DRG.
• Send clinical documentation to insurance companies per their request.
• Communicate with physicians on status changes and documentation.
• Refers cases for secondary review when appropriate.
• Refers cases for escalated medical review when services do not meet medical necessity criteria and/or appropriate level of care.
• Documents utilization reviews/issues in appropriate locations, including but not limited to case management/utilization review software.
• Track Avoidable days.
• Educates and assists physicians in resource utilization.
• Participate in extended care reviews and attend meetings.
• Review cases for potential quality indicators and refers to UM Leadership.
• Works with Appeal staff to actively appeal cases concurrently and retrospectively.

Qualifications

Educational Requirements:  College Diploma - Nursing Certification & Licensure Requirements

• Registered Professional Nurse (RN) License Illinois Upon Hire
• Satisfactorily complete all required continuing education regarding the care of acute stroke patients. Case Management Certification preferred.

Other Requirements

 

Able to establish professional relationships with all healthcare providers, work independently and collaborate, have strong communication and organizational skills and attention to detail.

Carle Health Company Overview

Find it here.

Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.

 

Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois.  We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

 

 

 

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.

Salary Range

The compensation range for this position is $35.87per hour - $58.37per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.