May be eligible for $3,000 sign on incentive
May be eligible for relocation assistance
May be eligible for tuition loan reimbursement

Under the direction of department leadership, the Utilization Review/ Management RN. This position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, and coordination to decrease avoidable denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments.

Essential Job Functions

•Supports and models behaviors consistent with BillingsClinic’s mission, vision, values, code of business conduct and serviceexpectations. Meets all mandatory organizational and departmental requirements.
•Maintainscompetency in all organizational, departmental, and outside agencyrequirements.
•Theresponsibilities of the UR case manager are listed below, in order of priorityand intended to ensure effective prioritization of tasks.
•Priority1: Reviews New Admissions, Observation and Outpatient Cases
•Prioritizereviews of all OBS and bedded Outpatients
•Communicatewith attending physician to discuss case and obtain information not documentedin record, when OBS cases do not meet payer criteria or OBS ≥ 24 hours
•Communicatewith attending physician for OBS patients meeting medical necessity forinpatient level of care to obtain inpatient order
•Communicatewith Case Manager to understand discharge plan and barriers to discharge on OBSand Outpatient in a Bed patients
•Participatein daily OBS call and communicate why patient is here, what we need from theteam to get the patient to the next level of care, and expected discharge plan
•Ensurethat admission review is completed on assigned units/worklist using payer MCGor CMS 2 Midnight Rule within 24 hours of admission
•Identifyincomplete reviews from worklist
•ValidateOBS orders daily for new admissions, within 24 hours
•Ensureorder in chart coincides with the payer review, CMS 2 Midnight Rule, or payerauthorization for status and level of care
•Priority2: Performs Utilization Review (UR) Activities
•Completesconcurrent Level of Care (LOC) & status reviews utilizing payer criteria toassure all days of hospitalization are covered/certified or meet CMS 2 MidnightRule (as appropriate) at minimum of every 3 days or more frequently based onpayer requirements
•Reviewsobservation patients at a minimum twice a day. Communicates with attending onmedical plan and Case Manager on discharge plan to expedite progression to nextlevel of care or discharge
•Discussescase with attending when payer authorization does not match status or level ofcare.
•Obtainsinformation not documented in the EMR and requests documentation of medicalnecessity to support appropriate status (IP, OP, OBS) and level of care(Med-surg, SDU, ICU, etc.)
•Ifattending is unable to provide additional clinical information supportingstatus or LOC, escalate case to the physician advisor for second level reviewas early as possible and before leaving for the day
•Communicatesto Case Manager any discrepancies on status or level of care based on medicalnecessity and/or payer authorization discrepancies
•Communicatesto Case Manager on current outliers, potential outliers, and denials
•Identifiesreviews that need to be completed on assigned floors and follows all assignedpatients through completion and submission of Discharge Summary
•Assessesif all days are authorized/certified by respective payers and communicate anyissues/denials to attending physician, CM, and department leadership
•ConductsUR until all tasks are completed; indicates UM Complete in authorization and/orcertification
•Communicateswith payer UR representatives on status/level of care authorizations that donot match MCG review
•Denotesrelevant clinical information to proactively communicate with payers forauthorizations of treatments, procedures, and Length of Stay; sends clinicalinformation as required by payer
•Notifiesappropriate parties of any changes in financial class including conversions,Hospital-Issued Notices of Noncoverage (HINN), Condition Code 44, and ImportantMessage from Medicare (IMM).
•Followsdepartment procedures and policies for Condition Code44, Physician Advisorreview, and HINN processes
•DocumentsAvoidable Days/Delays, per department process/procedure/policy
•Priority3: Maintains an Active Role in Denial Prevention and Management
•Usespayer MCG criteria and supporting documentation to justify the patient’smedical necessity for observation, admission and/or continued stay
•Proactivelyinteracts with payers and proactively sends clinical reviews to preventinpatient denials
•Proactivelycommunicates with payer UM representatives on denials and coordinate peer topeer review with payer’s medical director
•Initiatesand coordinates peer to peer reviews on all concurrent denials
•Understandspayer requirements and government regulations to ensure compliant, safe, andcost-effective healthcare
•Priority4: Identify Prolonged LOS patients, readmission, or complex discharge needspatients
•IdentifiesProlonged LOS patients or complex patients/situations and communicate to the CMand/or Social Worker as appropriate
•Priority5: Escalation
•Referscases that require second level review to Physician Advisor, Manager, andDirector per department process or procedure
•Discussesstatus/level of care and payment barriers with attending for resolution, ifunsuccessful, escalate to department leadership and Physician Advisor, perdepartment process or procedure
•Insuranceand Utilization Management
•Maintainsworking knowledge of CMS requirements and readmission penalties
•Maintainsworking knowledge of insurance/payer benefits
•Documentation
•Documentsaccurately and in a timely manner in the Electronic Medical Record per programguidelines
•Utilizesstandards of professional practice in all documentation and communicationconsistent with organization/department policy as well as the Board of Nursingand ethical guidelines established and universally supported by the nursingprofession
•Assuresdocumentation and patient information is secure and maintained in accordancewith Billings Clinic policy, HIPPA, state and federal guidelines
•ProfessionalAccountabilities
•Participatesin continuing education, department planning, work teams and processimprovement activities
•Maintainscurrent Licensure
•Adheresto department and organizational policies addressing confidentiality, infectioncontrol, patient rights, medical ethics, advance directives, disaster protocolsand safety
•Demonstratesthe ability to be flexible, open minded and adaptable to change
•Maintainscompetency in organizational and departmental policies/processes relevant tojob performance
•Utilizesstandards of professional practice in all communication with patients, supportsystems and colleagues consistent with the Board of Nursing and ethicalguidelines established and universally supported by the nursing profession
•Maintainutilization review data, as assigned by department.
•Performsall other duties as assigned or as needed to meet the needs of thedepartment/organization