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Legacy Health Utilization Management RN Specialist in United States

Serves as the interdisciplinary team expert and consultant regarding appropriate classification determinations. Ensures adherence to medical necessity criteria, regulatory requirements, and insurance rules. Acts as the primary denials prevention agent by performing admission and continued stay reviews as per government and commercial payor contractual requirements, to include the JCAHO Utilization Review Standard. Responsible for timely provision and flow of clinical information to and from third party payors and Care Management staff to ensure authorization of hospital services. Collaborates with the healthcare team, as well as Compliance and Revenue Cycle partners, on issues related to: continued stay, avoidable days, readmissions, RAC denials, second level reviews, outlier issues, and denials management. Serves as a contributing member of the Utilization Management Committee.

  • Reviews hospital admissions using approved criteria to verify documentation of appropriateness of admission and classification determination. Refers cases to secondary reviewer as needed.

  • Collaborates with patient’s attending physician regarding level of care and medical necessity determinations. Obtains physician second level review as needed.

  • Ensures that the appropriate classification order is present in each medical record and monitors for compliance with Medicare’s Inpatient Only list.

  • Reviews medical charts for concurrent review purposes to verify documentation of the plan of care and that the patient’s response to this treatment justifies the need for continued hospitalization.

  • Communicates with representatives of insurance plans to provide required documentation of medical necessity and obtain authorization for hospital days.

  • Collaborates with the healthcare team and serves as the point person to communicate ongoing information regarding authorized days, classification changes, regulatory concerns or denial issues.

  • Communicates directly with patients and families as needed to notify and educate on issues pertaining to utilization management including observation classification, medical necessity, insurance regulations, denials and appeals etc.

  • Communicates to and educates physician groups on issues of medical necessity and regulatory issues pertaining to utilization management.

  • Communicates with Patient Business Services (PBS) regarding questions of patient classification, level of care, or denial issues.

  • Informs appropriate Care Management staff and PBS of potential denials.

  • Partners with denials management staff to provide expert advice on medical necessity appeals.

  • Concurrently identifies and screens for quality indicators, referring issues to leadership when appropriate.

  • Documents interactions with payors in the Care Management software to enhance operation efficiencies.

  • Maintains documentation of current authorizations.

  • Collaborates system-wide to create solutions to utilization management issues including medical record classification concerns, appeal processes, quality improvement projects and other topics as they arise.

  • Provides key metric and analysis of UM trends and patterns to the Care Management team and Utilization Management Committee.

Education:

Academic degree in nursing (BSN or MSN/MN) required; MSN/MN preferred. Internal candidates may be considered with verification of a BSN or MSN/MN in progress, to be completed prior to 12/31/2021.

Experience:

This position requires extensive knowledge of diseases, procedures, treatments, prognosis, medical necessity requirements and healthcare reimbursement. Minimum 2 years of acute care nursing required. Relevant experience in one or more of the following areas preferred:

Utilization Management

Care coordination of diverse patient populations

Knowledge of levels of care throughout the health care continuum

Denials prevention and management

Licensure/Certification:

Current applicable state RN licensure required. AHA BLS for Healthcare Providers required for all employees who perform this job in the state of Oregon. Certification preferred in at least one of the following:

Certified Professional in Healthcare Management (CPHM)

InterQual Certified Instructor (IQCI)

Health Care Quality and Management (HCQM)

Certified Case Manager (CCM)

Accredited Case Manager (ACM)

Posting Title: Utilization Management RN Specialist

Job Req #: 21-16603

FTE for each opening (not total FTE across all openings for multiple openings). If less than 1.0 please enter leading 0 before the decimal, e.g. 0.2: 0.00

Job_Commensurate with Experience: USD $40.97/Hr. - USD $59.49/Hr.

FLSA Status: Non-Exempt

Union: Non-union

Work Days: Variable schedule

Shift Length: 8

Shift Start Time (HH:MM AM or PM): 0800

Shift End Time (HH:MM AM or PM): 1630

External Company Name: Legacy Health

External Company URL: https://www.legacyhealth.org/

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