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2 weeks ago
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.
- 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.
- 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.
- 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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