The Utilization Management Nurse collaborates with the healthcare team to coordinate patient care, ensure appropriate level of care, and manage timely authorizations. They perform admission and continued stay reviews while documenting clinical activity to ensure optimal reimbursement and regulatory compliance.
A Brief Overview
Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks to result in: Support of positive patient health care outcomes increased patient/health care team outcomes and satisfaction Improved inpatient throughput and appropriate length of stay Improved communication, awareness and adherence to regulatory requirements associated with utilization management Support for appropriate level of care and decreased inpatient bed day denials. Continuity and coordination of care Appropriate and timely authorization for level of care Decreased denials Appropriate reimbursement
What You Will Do
Performs timely and accurate admission and continued stay review in accordance with department policy to ensure efficient use of hospital resources, timely discharge and optimal, appropriate reimbursement (includes communication with internal and external customers).
Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to promote timely and effective communication, completion of workflow and services with regard to level of care decisions and payor decisions regarding continued stay.
Documents review activity, including but not limited to, application of criteria or policy as appropriate, clinical review to submit to insurance providers, initiation of registration changes when appropriate, outcomes and cost savings in a manner consistent with department requirements.
Meets department productivity and quality standards.
Additional Responsibilities
Performs other duties as assigned.
Complies with all policies and standards.
For specific duties and responsibilities, refer to documentation provided by the department during orientation.
Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.
Education
Graduate of an accredited school of Nursing (Required)
Bachelor's Degree (Preferred)
Work Experience
3+ years of clinical experience (acute care) (Required)
Additional experience in sub-acute setting, or managed care (Preferred)
2+ years of clinical experience with the population to be served. (recommended) (Required)
Prior UM experience (Preferred)
Experience with Interqual or MCG criteria (Preferred)
Knowledge, Skills, & Abilities
Must have sound clinical knowledge base of the population to be served. (Required proficiency)
Knowledge of Medicare, Medicaid and commercial payer regulations (Preferred proficiency)
Detail-oriented and organized, with good analytical/critical thinking skills and problem solving ability. (Required proficiency)
Ability to function independently and as a team player in a fast-paced environment (Required proficiency)
Must have strong written and verbal communication skills. (Required proficiency)
Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.) (Required proficiency)
Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines (Required proficiency)
Licenses and Certifications
Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire)
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