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Nurse Reviewer for Utilization Management

2 months ago

Wooster, Ohio, United States Wooster Community Hospital Full time
Job Overview

Remote position available within a 2-hour drive of Wooster Community Hospital

Part-time role (24 hours/week) focused on weekend coverage (Saturday, Sunday, Monday) in Utilization Management

POSITION SUMMARY:

The Nurse Reviewer for Utilization Management (RN) acts as the Subject Matter Expert (SME) within the organization regarding patient admission classifications (both inpatient and observation). This role collaborates with healthcare Providers, Case Management, and the Revenue Cycle team to ensure the correct admission status is maintained. The UM RN safeguards the organization’s financial interests by ensuring the UM review process is effectively completed from admission through to the appeal of any denials encountered.

REPORTING STRUCTURE:

Reports directly to the System Director of Revenue Cycle.

ESSENTIAL QUALIFICATIONS:

  • Active RN license in Ohio
  • 3-5 years of clinical nursing experience across diverse settings
  • 1-3 years of experience in Utilization Management within an acute care environment
  • Familiarity with InterQual and/or Milliman criteria
  • Comprehensive understanding of reimbursement methodologies
  • Strong organizational, prioritization, and delegation capabilities
  • Proven emotional intelligence, including self-control, self-awareness, social awareness, and relationship management
  • Exceptional verbal and written communication skills
  • Ability to work autonomously in a dynamic environment while meeting deadlines
  • Proficient in resolving complex, multifaceted issues
  • Competent in using computers and analytical software

PREFERRED QUALIFICATIONS:

  • Bachelor's degree
  • Certification in Utilization Management
  • Robust knowledge of Medicare/Medicaid regulations concerning UM and billing compliance
  • Experience with MCG Indicia tools

ROLE EXPECTATIONS:

  • Adhere to service standards while conducting clinical reviews of all acute bedded patients admitted to inpatient or observation status against medical necessity criteria (InterQual or MCG), utilizing available tools (Meditech, MCG Indicia, payer portals) and prescribed processes.
  • Ensure timely submission of continued stay reviews as per payer requirements, ensuring coverage for all days of the stay.
  • Monitor submitted cases for timely payer responses to address any potential denials proactively.
  • Document all case reviews thoroughly in MCG Indicia/Meditech, including submission methods, results, and communications with relevant parties.
  • Facilitate peer-to-peer discussions between attending providers and payers as necessary.
  • Participate in daily huddles with Case Management and the Physician Risk Advisor (PRA) to stay informed and contribute as the SME on status matters.
  • Collaborate closely with Case Management to ensure proper utilization and status management.
  • Identify and report denials in accordance with established procedures, ensuring timely appeals are submitted.
  • Maintain productivity standards as outlined for reviews per shift.
  • Support the UM Clerical team in following up on appeal responses.
  • Work with the UM Lead Nurse Reviewer to identify process improvement opportunities and communicate findings to leadership.
  • Engage with the PRA, Director, and UM Lead Nurse Reviewer to address any issues for the quarterly UM Committee.
  • Perform additional duties as assigned, including adherence to all departmental and organizational policies, maintaining compliance with state and federal guidelines, and demonstrating a positive attitude and openness to feedback.