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Registered Nurse
2 months ago
Typical Pay Range:
$66.65ST
ST. CHARLES HEALTH SYSTEM JOB DESCRIPTION TITLE:
RN Utilization Management
REPORTS TO:
Manager - Utilization Management
DEPARTMENT:
Utilization Management
OUR VISION:
Creating America's healthiest community, together
OUR MISSION:
In the spirit of love and compassion, better health, better care, better value
OUR VALUES:
Accountability, Caring, and Teamwork
DEPARTMENTAL SUMMARY:
The Utilization Management (UM) Department is dedicated to fostering a centralized, collaborative, and multidisciplinary approach to utilization management across St. Charles Health System (SCHS).
The UM Department aids healthcare providers and clinical personnel in recognizing and enhancing care processes and systems to establish and ensure medical necessity, appropriate service utilization, and compliance with all relevant regulations.
POSITION OVERVIEW:
The Utilization Management Registered Nurse (RN) possesses advanced knowledge and skills in utilization management, medical necessity, and patient status determination.
The UM RN contributes to the UM program by developing and maintaining effective processes for determining the appropriate admission status in accordance with the regulatory and reimbursement requirements of various payers.
The UM RN is tasked with conducting a variety of concurrent and retrospective UM-related reviews and functions, ensuring that pertinent data is tracked, evaluated, and reported.
In instances where screening criteria do not align with physician orders or a status conflict arises, the UM RN is responsible for escalating the matter to the Physician Advisor or designated leader for further review as per departmental standards.
The UM RN plays a crucial role in denial avoidance strategies, including concurrent payer communications to resolve status disputes.Moreover, the UM RN monitors the effectiveness and outcomes of the UM program, identifying and applying appropriate metrics, evaluating data, reporting results to various stakeholders, and designing and implementing process improvement initiatives as necessary.
This position does not involve direct management of other caregivers.ESSENTIAL FUNCTIONS AND DUTIES:
Acts as an integral member of the interdisciplinary team within the UM Department, may be responsible for providing cross-coverage for roles and responsibilities of other UM team members during earned time off and/or during backlogs due to peak volumes.
Ensures appropriate patient status upon admission and manages patient status conversions as necessary.
Completes admission medical necessity reviews within 24 hours of admission.
Conducts concurrent inpatient medical necessity reviews at least every three (3) days unless otherwise specified by the payer.
Completes Observation medical necessity reviews at least every 12 hours (twice daily) and Medicare extended stay reviews as appropriate.
Assigns an initial working DRG & GMLOS upon completion of the initial medical necessity review for inpatient admissions and enters this information in the EMR. Completes discharge reviews and ensures completeness of all prior medical necessity reviews and authorizations; escalates concerns as necessary.
Identifies and escalates all 1MN and 2MN Medicare inpatient stays.Collaborates with the Care Management (CM) team as appropriate (i.e., extended observation stays, patients no longer meeting medical necessity, status changes).Collaborates with physicians as needed (i.e.,
to address issues concerning medical necessity, status orders, appropriate level of care, peer-to-peer involvement, etc.).Collaborates with payers as necessary (i.e.,
to discuss status, changes in level of care, changes in pre-authorizations warranting reauthorization, etc.).Communicates and collaborates with Patient Access, Patient Financial Services (PFS), and Health Information Management (HIM) as appropriate.
Escalates Medical Necessity (patient status / level of care) concerns and other UM issues to the Physician Advisor or designated leader as necessary.
Assists with the discharge appeal process as appropriate.Provides timely and continuous coverage of assigned work area to ensure all accounts are complete.
Assists in identifying Avoidable Days and communicates information with CM as appropriate.
Complies with all documentation requirements.
Follows up on action items prior to the end of the shift.
Maintains a working knowledge of payer contracts and regulatory requirements, as well as UM-specific changes (i.e., changes in authorizations, payer contracts, CMS, regulatory requirements).Completes all tasks within departmental guidelines.
Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state governing bodies.
Provides support regarding Medicare documentation requirements.
Obtains verbal admission orders from physicians and monitors for authorization by the physician.
Participates in delivering regulatory forms to patients when appropriate.
Communicates with insurance companies regarding the medical necessity of admissions and provides clinical documentation and reviews to insurance companies as requested for ongoing authorization of hospital stays.
Actively participates in clinical performance improvement activities.Assists in collecting and reporting resource and financial indicators including length of stay, cost per case, avoidable days, resource utilization, readmission rates, concurrent denials, and appeals.
Supports the vision, mission, and values of the organization in all respects.Embraces Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Ensures a safe environment for caregivers, patients, and guests.Conducts all activities with the highest standards of professionalism and confidentiality.
Complies with all applicable laws, regulations, policies, and procedures, supporting the organization's corporate integrity efforts by acting ethically and appropriately, reporting known or suspected violations of applicable rules, and cooperating fully with all organizational investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate. May perform additional duties of similar complexity within the organization as required or assigned.EDUCATION:
Required:
Graduate of an accredited school of nursing
Preferred:
Bachelor's degree in Nursing or Health Care related field
LICENSURE/CERTIFICATION/REGISTRATION:
Required:
Current Oregon RN license
Preferred:
ACM (Accredited Case Manager) through AMCA (American Case Management Association); CCM (Certified Case Manager); CCMC (Commission for Case Manager Certification)
EXPERIENCE:
Required:
Three (3) years of acute care clinical nursing experience
Preferred:
Five (5) years of clinical experience in an acute care facility
Two (2) years of Utilization Management experience, or equivalent professional experience
Two (2) years of experience working in electronic health records
PERSONAL PROTECTIVE EQUIPMENT:
Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely
ADDITIONAL POSITION INFORMATION:
Skills:
Advanced critical thinking and conflict resolution skills, working knowledge of regulatory and survey standards (Medicare, Joint Commission); working knowledge of status determination criteria (InterQual or MCG) and ability to apply consistently according to interrater reliability techniques; working knowledge of rapid-cycle process improvement.
General:
Ability to effectively interact and communicate with all levels within St. Charles Health System and external customers/clients/potential employees.
Strong teamwork and collaborative skills.
Ability to multitask and work independently.
Attention to detail.
Excellent organizational skills, written and oral communication, and customer service skills, particularly in dealing with stressful personal interactions.
Strong analytical, problem-solving, and decision-making skills.
Demonstrated ability and experience in computer applications, use of electronic medical record keeping systems, and MS Office.
PHYSICAL REQUIREMENTS:
Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.
Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.
Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.
Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.
Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.
Exposure to Elemental Factors
Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.
Blood-Borne Pathogen (BBP)
Exposure Category: No Risk for Exposure to BBP
Schedule Weekly Hours: 40
Caregiver Type:
Regular
Shift: First Shift (United States of America)
Is Exempt Position? No
Job Family:
NON CONTRACT RN SPECIALISTS
Scheduled Days of the Week: As Scheduled (may include weekends and holidays)
Shift Start & End Time: 8-1630
