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Fairview Health Services Utilization Management Specialist RN in Minneapolis, Minnesota


M Health Fairview has an immediate opening for a Utilization Management Specialist RN. This position provides comprehensive assessment, planning, coordination, implementation, and reporting of complex clinical data.

The utilization management specialist is responsible for the completion of admissions and continued stay reviews, obtaining insurance certification/authorization necessary to secure reimbursement. This position assesses the patient’s plan of care and progress of the patient throughout an acute care and/or outpatient episode across the Fairview system. The intensity of assessment is situational and appropriate based on payer requirements. The utilization management specialist concurrently monitors the appropriateness of admission and continued stay days using InterQual criteria and Fairview guidelines. This position identifies/resolves barriers which may hinder effective patient care.

This is a 1.0 FTE (80 hours per two week pay period), benefit-eligible position.

This position will work out of M Health Fairview's offices located at 400 Stinson Boulevard, Minneapolis, MN.

Responsibilities/Job Description

Performs utilization management in accordance with all policies, procedures, regulatory and accreditation requirements, as well as application professional standards.

Evaluates patient progress daily via chart review and/or collaboration with care transitions specialist. Obtains necessary medical reports and subsequent treatment plan requests to conduct ongoing reviews.

Applies evidence based criteria to determine appropriateness of level of care, length of stay, and discharge planning.

Collaborates with physician advisor and/or primary physician on all cases related to level of care and status.

Documents review information in chart, as appropriate.

Acts as financial steward by optimizing the patient’s medical benefits, as well as optimizing reimbursement.

Ensure Medicare guidelines are followed including facilitation of appeals related to medical necessity or appropriateness.

Analyzes patient records and participates in interdisciplinary collaboration with health care team.

Collaborates with health care team partners, including care transition specialists, care coordinators, physicians, clinicians, payers, non-clinical staff, HIM’s, central business office, admissions, patient placement and clinical managers on level of care, identified barriers, reimbursement issues, and other issues related to utilization management activities.

Understands and follows system and facility UM plans.

Works with compliance to ensure documentation meets regulatory requirements.

Participates in interdisciplinary communication related to utilization review issues.

Educates on status. Provides all customers with excellent service experience.



Bachelor’s degree or currently serving in the role (grandfather status)

Current RN licensure in MN

3-5 years utilization review or case management experience in hospital, clinic, insurance company or long term care facility

Prior Epic EMR experience


Prior Utilization Review experience is highly preferred

Prior experience with InterQual is highly preferred

Prior patient care experience is preferred

Prior performance improvement experience is preferred

Ability to work independently, prioritize work, and excellent communication skills

Excellent computer and database management skills

Must have working knowledge of use of evidence based guidelines

Must demonstrate critical thinking skills, problem-solving ability, effective communication skills and time management skills

Must demonstrate ability to work effectively on an interdisciplinary team

Must be able to work flexible hours, including covering weekends, evenings, and on call, as assigned.

Must be willing to travel to other Fariview sites as needed.

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Fairview Health Services ( is an award-winning, nonprofit health system providing exceptional care across the full spectrum of health care services. Fairview is one of the most comprehensive and geographically accessible systems in the state, with 12 hospitals—including an academic medical center and long-term care hospital—serving the greater Twin Cities metro area and north-central Minnesota.

Its broad continuum also includes 56 primary care clinics, specialty clinics, senior living communities, retail and specialty pharmacies, pharmacy benefit management services, rehabilitation centers, counseling and home health care services, medical transportation, an integrated provider network and health insurer PreferredOne. In partnership with the University of Minnesota, Fairview’s 32,000 employees and 2,400 affiliated providers embrace innovation to drive a healthier future through healing, discovery and education.

EEO/AA Employer/Vet/Disabled All qualified applicants will receive consideration without regard to any lawfully protected status.

Job Locations US-MN-Minneapolis

Requisition Post Information* : Posted Date 4 days ago (9/16/2020 9:26 AM)

Requisition ID 2020-61502

Profession Nursing (RN/LPN)

Speciality Nursing Resources/Education/Care Mgmt

Location Fairview offices at 400 Stinson

Shift day/evening

Hours per 2 weeks 80

Department Utilization Mgmt Community