Utilization Management Nurse

3 weeks ago

Cleveland, United States University Hospitals Full time
Description

Position Summary

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

Essential Functions

  • 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.

Required For All Jobs

  • 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.
Qualifications

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  
  • Experience with Interqual or MCG criteria Preferred

Knowledge, Skills, & Abilities

  • Must have sound clinical knowledge base of the population to be served. Required
  • Knowledge of Medicare, Medicaid and commercial payer regulations Preferred
  • Detail-oriented and organized, with good analytical/critical thinking skills and problem solving ability. Required
  • Ability to function independently and as a team player in a fast-paced environment Required
  • Must have strong written and verbal communication skills. Required
  • Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.) Required
  • Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines Required

Licenses and Certifications

  • Registered Nurse (RN) in the State of Ohio Required

Additional Licenses and Certifications

  • CM certificate Preferred 

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