Nurse Clinician

2 weeks ago


Iowa City, Iowa, United States The University Of Iowa Full time
Job Summary

We are seeking a highly skilled Nurse Clinician to join our Utilization Management Team at The University of Iowa Healthcare University Campus. As a clinical nurse expert and coordinator, you will play a critical role in ensuring reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed.

Key Responsibilities
  • Conduct concurrent reviews as directed in the hospital's Utilization Review Plan and review of medical records to ensure criteria for admission and continued stay are met and documented.
  • Collaborate with the healthcare team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity.
  • Validate commercial payer authorization within the contractual time frame at time of presentation, every third day or as needed.
  • Manage concurrent cases to resolution, ensuring payer approval to authorize care as medically necessary.
  • Participate in the resolution of retrospective reimbursement issues, including appeals, third-party payer certification, and denied cases.
  • Provide clinical information to relevant clinical team members regarding patient needs and/or newly identified issues.
  • Review data specific to utilization management functions and reports as requested.
  • Monitor effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics.
Requirements
  • A Baccalaureate degree in Nursing is required.
  • Current license to practice nursing in Iowa is required by date of hire.
  • 3 - 5 years of RN clinical nursing experience.
  • Excellent written and verbal communication skills.
Preferred Qualifications
  • Professional Masters of Nursing and Healthcare Practice (MNHP), MSN/Clinical Nurse Leader, or a Master's Degree in Nursing (MSN, MA).
  • Previous experience performing Utilization Reviews in an RN capacity.
  • Previous experience involving high-volume public contact customer service.
  • Previous experience working in an electronic medical record.
  • Previous case management or utilization management experience.
  • Certification in case management (i.e. ACM, CCM, or CMAC).
  • Previous experience with EPIC.
What We Offer
  • A regular salaried position located in Iowa City, Iowa.
  • A fringe benefit package including paid vacation, sick leave, health, dental, life, and disability insurance options, and generous employer contributions into retirement plans.

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