Utilization Management RN

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