Utilization Management Nurse
4 weeks ago
As a Utilization Management Nurse at MUSC Health & Medical University of SC, you will play a critical role in determining and managing medical necessity of acute inpatient and IOP admissions. This involves utilizing clinical criteria to assess the appropriateness of care and collaborating with physicians and other healthcare professionals to ensure quality, cost-effective care.
Key Responsibilities- Responsibility A: Comprehensive Care Planning
- Assess, develop, implement, and monitor comprehensive care plans through an interdisciplinary team process.
- Accountable for current knowledge of utilization management responsibilities, including payer information, business rules, regulatory guidelines, and policies and procedures.
- Responsibility B: Quality and Cost-Effective Care
- Communicate with commercial or MMC payers to certify inpatient days as required.
- Maintain accurate documentation of all communication and interventions in the EMR.
- Responsibility C: Community Health Outreach
- Collaborate with community health education/outreach organizations and providers to promote health for patients with complex healthcare needs.
- Proactively intervene with medical necessity or level of care denials by exercising all real-time options to overturn decisions.
- Responsibility D: Data Analysis and Quality Improvement
- Prepare and monitor outcome data to assist in the identification of improvement opportunities.
- Identify and monitor improvement opportunities along the continuum of care.
- Responsibility E: Team Collaboration and Communication
- Demonstrate commitment to team, flexibility, professional interpersonal, communication, critical thinking, and customer service skills.
- Advance clinical expertise through attendance at in-hours education opportunities, reading journals, and attendance at conferences.
- Bachelor's degree in Nursing from an accredited school of nursing.
- Three years' work experience as a Registered Nurse.
- Prior leadership experience preferred.
- One year of case management and/or utilization management work experience preferred.
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Utilization Management Nurse
4 weeks ago
Washington, Washington, D.C., United States MUSC Health & Medical University of SC Full timeJob SummaryAs a Utilization Management Nurse at MUSC Health & Medical University of SC, you will play a critical role in determining and managing medical necessity of acute inpatient and IOP admissions. This involves utilizing clinical criteria to assess the appropriateness of care and collaborating with physicians and other healthcare professionals to...
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