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