Clinical Utilization Manager RN

1 month ago


Valley Center, Kansas, United States Bryan Health Full time
Job Summary

Bryan Health is seeking a skilled Clinical Utilization Manager RN to join our team. As a key member of our healthcare team, you will play a vital role in ensuring the efficient and effective management of patient care.

Key Responsibilities
  • Conduct daily activities to coordinate clinical, financial, and utilization aspects of patient care.
  • Collaborate with interdisciplinary teams, including hospital staff, physicians, and patient support, to ensure patient hospital stays meet medical necessity and insurance authorizations are obtained.
  • Perform utilization review activities, including concurrent and retrospective reviews, to determine medical necessity of treatment requests.
  • Collaborate with patient providers and healthcare teams to manage patient length of stay and determine continuing medical necessity of care.
  • Refer cases to reviewing physicians when treatment requests do not meet criteria.
  • Participate in concurrent and retrospective denials and appeals processes, researching issues and participating in all levels of appeal.
  • Serve as an internal and external resource for appropriate level of care, admission status, Medicare/Medicaid rules, and discharge planning.
Requirements
  • Current Registered Nurse licensure from the State of Nebraska or approved compact state.
  • Minimum of two years recent clinical experience required.
  • Prior care coordination and/or utilization management experience preferred.
Certifications

Basic Life Support (CPR) certification required.

Physical Requirements

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)



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