Utilization Management RN

**Schedule: Full-time days- Monday through Friday with shared rotating weekends.** **Fully in person position**** Do you want to work in a culture where interdisciplinary teams come together to improve care, where your suggestions are welcomed and your ideas are part of the solution? Explore the Thompson difference and apply today! **** UR Medicine's Thompson Health is the premier healthcare provider in the Finger Lakes region. You will enjoy a competitive salary and generous benefits, free onsite parking, an excellent staffing model and a modern, caring, high-tech environment.**

Internal Title: **Utilization Management / CDS Nurse ( RN )**

UM/CDS Nurse Responsibilities

• Perform extensive record review in accordance with state regulations, ensuring compliance with changes affecting Utilization Management and Clinical Documentation Improvement.
• Assess the appropriateness and medical necessity of treatment requests on a prospective, concurrent, and retrospective basis.
• Collaborate with providers to determine appropriate admission status and potential changes using critical thinking skills and recognized criteria.
• Interact frequently with providers, HIM professionals, Social Workers, nursing staff, patients/patients' caregivers, and insurance companies.
• Review medical records to improve clinical documentation, representing the severity of illness, risk of mortality, and patient complexity.
  
  

Description

• **Perform utilization review** in accordance with state regulations, ensuring compliance with changes affecting Utilization Management **.**
• **Collaborate with providers** to determine appropriate admission status and potential changes.
• **Assess the appropriateness and medical necessity** of treatment requests for utilization review on a prospective, concurrent, and retrospective basis.
• **Review patient records and evaluate progress** , obtaining necessary medical reports and treatment plan requests.
• **Review medical records** to improve the quality of clinical documentation, representing the severity of illness, risk of mortality, and patient complexity.
• **Provide review information to payers** as requested.
• **Perform retroactive reviews** for assigned denials and monitor steps throughout the denial process.
• **Write effective appeal letters** and inform appropriate departments of outcomes.
• **Work with Medical Staff, Case Management/Social Work, Clinical Quality, and interdisciplinary care team** to ensure quality patient outcomes through appropriate utilization of hospital resources.
• **Collect, analyze, and maintain data** on the utilization of medical services and resources to identify trends and opportunities for improvement.
• **Serve as primary contact** for Utilization Management related issues, both internally and externally.
• **Assess quality and clinical risk issues** on a concurrent basis, reporting quality of care issues as identified.
• **Provide education** to medical staff, department leaders, medical offices, and associates on Utilization Management principles, including the use of InterQual & Milliman criteria and CMS regulations.
• **Actively participate in committees and workgroups** related to Utilization Management, Length of Stay Management, Readmissions and Observation services.
• **Collaborate and assist the manager** in executing a Quality and Safety model, integrating regulatory mandates, and providing training for JC readiness.
• **Participate in team meetings and staff education** in the Utilization Management process and Clinical Documentation Improvement Program.
• Required Competencies** :
• **Demonstrated Knowledge or willingness to learn:** Utilization Management principles including knowledge of various regulatory and payer specific requirements.
• **Clinical Knowledge** : Proficiency in clinical criteria and understanding of medical treatments and interventions.
• **Critical Thinking** : Ability to assess the appropriateness and medical necessity of treatment requests.
• **Regulatory Awareness** : Knowledge of state and federal regulations guiding the authorization, denial, and appeal processes.
• **Communication Skills** : Effective interaction with providers, HIM professionals, Social Workers, nursing staff, patients, caregivers, and insurance companies.
• **Documentation Skills** : Accurate and thorough documentation to support clinical decisions and ensure compliance.
• **Analytical Skills** : Ability to collect, analyze, and maintain data on the utilization of medical services and resources.
• **Demonstrate attention to detail** in all aspects of documentation and review processes.
• **Prioritize tasks effectively** to manage multiple responsibilities and deadlines.
• **Adapt to changing situations** and regulatory requirements in the healthcare environment.
• **Patient Advocacy** : Ensuring patients receive appropriate and cost-effective healthcare services.
• **Collaboration** : Working effectively with interdisciplinary teams to ensure quality patient outcomes.
• **Adaptability** : Staying up to date with changes in healthcare regulations and best practices.
• **Lives the CARES values** at all times.
  
  

Requirements

Registered Nurse in NYS

Education

• A.A.S. in Nursing
• B.S. in Nursing or other Health related field or willingness to get one within 5 years of employment.
  
  

Experience

• Minimum 5 years of acute nursing experience.
• Prefer Utilization Review or Clinical Documentation Specialist experience.
• Experience working with physicians in a collaborative supportive manner.
• Knowledgeable in the use of nationally recognized criteria or willingness to learn.
• Knowledgeable in reimbursement methodologies & interpretation of payer contracts or willingness to learn.
• Experience with computer applications including Microsoft Office.
• Preferred experience with Epic.
• Preferred experience in writing effective appeal letters.
  
  

Complexity Of Duties

• Performs a variety of duties requiring independent judgment and decision-making and adjusting priorities as needed.
• Keeps abreast of complex and changing regulatory environment.
• Handle difficult situations with providers, patients and caregivers, using strong communication skills to diffuse situations and reach resolution.
• Effectively manage denials / appeals with attention to detail and follow-up.
• Competently issues Notices of Status Change, MOONs and HINNs/ABNs when appropriate.
  
  

**\*\*\* Shared weekends**

**Position Pay Range: $35.00-47.00/hour**

**Starting Pay: Based on experience**

• _Thompson Health is an EOE encouraging individuals with disabilities and veterans to apply_**