Full-Time

40 hours/week

Remote

Summary:

The Utilization Management Nurse is responsible for conducting medical necessity review to assure appropriate use of hospital resources, and serving as a resource to the hospital staff on utilization management practices.

Responsibilities:

1. Provides clinical review to health plans as required by the health plan and/or the Utilization Review plan and ensures all days are approved and authorized. Notifies physician advisor when patients do not meet admission or continued stay criteria.
2. Validates patient registration status with physician order against medical necessity screening criteria and applies evidence based medical necessity screening criteria as defined by the Utilization Review plan. Proactively confers with attending physician to provide coaching on accurate level of care determination at point-of-hospital entry. Ensures that all extended recovery and observation patients are screened at least daily for appropriate level of care.
3. Assists with denial management, peer review, and quality/safety work to identify opportunities to improve department/hospital processes. Identifies compliance and ethical issues and reports appropriately.
4. Actively participates in daily huddles, multidisciplinary rounds, and patient care conferences as needed to maintain knowledge about intensity of service, delays in service, barriers to discharge, and progression of care. Identifies and records episodes of avoidable days.
5. Clearly documents outcomes of all actions taken in Midas and Epic as appropriate.
6. Serves as a resource to the health care team on issues related to admission qualifications, resource utilization, and documentation improvement opportunities.
7. Other duties as required.

Other information:

Technical Expertise
1. Experience in inpatient clinical is required.
2. Experience in pediatrics is preferred.
3. Experience working with all levels within an organization is required.
4. Experience in healthcare is required.
5. Proficiency in MS Office [Outlook, Excel, Word] or similar software is required.
Education and Experience
1. Education: Bachelors in Nursing [BSN] is required. For employees hired after July 1, 2013, BSN is required or must be obtained within 5 years from date of hire.
2. Certification: Registered Nurse licensure is required.
3. Years of relevant experience: 3 to 5 years is preferred.
4. Years of experience supervising: None.

Full Time

FTE:

Status: Remote