RN Utilization Management Specialist

6 days ago

Saint Paul Minnesota, United States Fairview Health Services Full time
Job Summary

Fairview Health Services is seeking a skilled RN Utilization Management Specialist to join our team. As a key member of our clinical team, you will be responsible for providing comprehensive assessment, planning, coordination, implementation, and reporting of complex clinical data.

Key Responsibilities
  • Perform utilization management in accordance with all policies, procedures, regulatory and accreditation requirements, as well as application professional standards.
  • Evaluate patient progress daily via chart review and/or collaboration with care transitions specialist.
  • Obtain necessary medical reports and subsequent treatment plan requests to conduct ongoing reviews.
  • Apply evidence-based criteria to determine appropriateness of level of care, length of stay, and discharge planning.
  • Collaborate with physician advisor and/or primary physician on all cases related to level of care and status.
  • Document review information in chart, as appropriate.
  • Act 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.
  • Analyze patient records and participate in interdisciplinary collaboration with healthcare team.
Requirements
  • 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 Qualifications
  • 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 Fairview sites as needed

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