The RN - Utilization Management gathers clinical information to determine appropriateness of admission, continued stay, medical necessity, and appropriateness of patient status throughout a patient’s hospital stay. Efficiently processes payer authorization requests to obtain certification from insurance or payers. Collaborates with care managers, providers, discharge planners and other care team members.

Core Job Responsibilities

Complete initial admission reviews within 24 hours of admission, including reviews for those that were admitted during hours without an access nurse on duty.
Ensure the appropriate level of patient care by utilizing expert level of clinical decision making, standard level of care criteria, commercial payor criteria, and attending physician communication and input.
Consult with Physician Advisor for the cases not meeting criteria. Ensure that Physician Advisor Medical Necessity documentation is placed on the medical record and is available to the Attending Physician.
Coordinate peer to peer telephone calls between insurance representatives/payers and attending physicians or physician advisors as needed to appeal concurrent UR denials.
Complete daily utilization review of all observation/outpatient/in-bed patients. Collaborate with Care Manager to determine discharge plan is within observation parameters. Communicate with physicians regarding observation length of stay and plan of care.
Assist with ensuring that any status (class) order changes are documented, timed and dated in medical record and are accurate in EPIC.
Consult Care Managers for admissions which meet re-admission criteria.
Complete Continued Stay reviews on Medicare/Medicaid/Medicare HMO, VA, Hospice, and Self-pay patients.
Provide support and/or coverage to the Managed Care Reviewer for commercial UR and continued stay requests.
Maintain appropriate computer databases and apply appropriate tools for utilization review.
Perform related duties as assigned.

Education/Experience Requirements

REQUIRED:

Graduate of an accredited school of nursing program
3-5 years of applied clinical experience as a RN.
1 year of experience in Hospital Case Management.
Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets.
Ability to assess medical records and make determinations on length of stay and proper procedures.
Knowledge of documentation and billing practices, ability to identify billing problems and research issues at hand.
Excellent interpersonal, verbal and written communication skills.
Proficient with MS Office (Excel) and Epic EMR.

PREFERRED:

BSN

Licensure/Certification Requirements

REQUIRED:

NYS License as a Registered Nurse.

Disclaimer

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.
Successful candidates might be required to undergo a background verification with an external vendor.

Job Details

Req Id 97475
Department CASE MGMT
Shift Days
Shift Hours Worked 9.50
FTE 0.93
Work Schedule NYSNA - 9.5 x 4
Employee Status A1 - Full-Time
Union 2004 - NYSNA
Pay Range $40.19 - $56.51/Hourly

Nearest Major Market: Utica

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