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Utilization Management Specialist RN

2 months ago

St Paul, United States Fairview Health Services Full time
Overview

M Health Fairview has an immediate opening for a Utilization Management Specialist RN. This position provides comprehensive assessment, planning, coordination, implementation, and reporting of complex clinical data.

The utilization management specialist is responsible for the completion of admissions and continued stay reviews, obtaining insurance certification/authorization necessary to secure reimbursement. This position assesses the patient's plan of care and progress of the patient throughout an acute care and/or outpatient episode across the Fairview system. The intensity of assessment is situational and appropriate based on payer requirements. The utilization management specialist concurrently monitors the appropriateness of admission and continued stay days using InterQual criteria and Fairview guidelines. This position identifies/resolves barriers which may hinder effective patient care.

This is a 0.1 FTE casual opening. This role is not eligible for benefits.

Responsibilities Job Description

Performs utilization management in accordance with all policies, procedures, regulatory and accreditation requirements, as well as application professional standards.

Evaluates patient progress daily via chart review and/or collaboration with care transitions specialist. Obtains necessary medical reports and subsequent treatment plan requests to conduct ongoing reviews.

Applies evidence based criteria to determine appropriateness of level of care, length of stay, and discharge planning.

Collaborates with physician advisor and/or primary physician on all cases related to level of care and status.

Documents review information in chart, as appropriate.

Acts as financial steward by optimizing the patient's medical benefits, as well as optimizing reimbursement.

Ensure Medicare guidelines are followed including facilitation of appeals related to medical necessity or appropriateness.

Analyzes patient records and participates in interdisciplinary collaboration with health care team.

Collaborates with health care team partners, including care transition specialists, care coordinators, physicians, clinicians, payers, non-clinical staff, HIM's, central business office, admissions, patient placement and clinical managers on level of care, identified barriers, reimbursement issues, and other issues related to utilization management activities.

Understands and follows system and facility UM plans.

Works with compliance to ensure documentation meets regulatory requirements.

Participates in interdisciplinary communication related to utilization review issues.

Educates on status. Provides all customers with excellent service experience.

Qualifications

Required:
  • Bachelor's degree or currently serving in the role (grandfather status)
  • Current RN licensure in MN
  • 3-5 years utilization review or case management experience in hospital, clinic, insurance company or long term care facility
  • Prior Epic EMR experience
Preferred:
  • Minimum of 1-year Epic experience.
  • Minimum 1-year experience using medical necessity screening criteria, such as InterQual or MCG.
  • Minimum of 3-5 years of acute care hospital nursing experience.
  • Excellent computer and database management skills.
  • Prior Utilization Review experience is highly preferred
  • Prior experience with InterQual is highly preferred
  • Prior patient care experience is preferred
  • Prior performance improvement experience is preferred
  • Ability to work independently, prioritize work, and excellent communication skills
  • Excellent computer and database management skills
  • Must have working knowledge of use of evidence based guidelines
  • Must demonstrate critical thinking skills, problem-solving ability, effective communication skills and time management skills
  • Must demonstrate ability to work effectively on an interdisciplinary team
  • Must be able to work flexible hours, including covering weekends, evenings, and on call, as assigned.
  • Must be willing to travel to other Fariview sites as needed.

EEO Statement

EEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status