Utilization Management Spec RN

Overview:

Fairview Health Services is hiring a casual Utilization Management Spec RN to join our Revenue Cycle Management team. This is a remote position.

Two shifts a month would be considered casual for this position.

This position, under Revenue Cycle Management, is responsible for the completion of admission and continued stay clinical review, including 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 (observation) across the M Health Fairview system.

Responsibilities/Job Description:

Job Expectations:
• Perform and document timely and accurate utilization management review to ensure compliance with all policies, procedures, regulatory and accreditation requirements.
• Adhere to applicable professional standards using nationally recognized evidence-based clinical criteria and M Health Fairview guidelines to determine the appropriateness of level of care, length of stay and discharge planning.
• Facilitate secondary physician review with the physician advisor and/or attending physician on required cases to ensure accurate level of care assignment and reimbursement.
• Manage resolution of concurrent payer denials through submission and coordination of appeals related to medical necessity (level of care) and tracks all work related to denials/appeals.
• Educate internal members of the health care team on utilization management workflow and managed care concepts.
• Work on a variety of special projects and assume other duties as assigned by the Utilization Review Manager or Supervisor.
• Understand and focus on key performance indicators.
• Contribute to the process or enablement of collecting expected reimbursement.
• Understand and adhere to Revenue Cycle’s Escalation Policy.

Organization Expectations, as applicable:
• Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served.
• * Partners with patient care giver in care/decision making.
• Communicates in a respective manner.
• Ensures a safe, secure environment.
• Individualizes plan of care to meet patient needs.
• Modifies clinical interventions based on population served.
• Provides patient education based on as assessment of learning needs of patient/care giver.
• Fulfills all organizational requirements.
• Completes all required learning relevant to the role.
• Complies with and maintains knowledge of all relevant laws, regulations, policies, procedures, and standards.
• Fosters a culture of improvement, efficiency, and innovative thinking.
• Performs other duties as assigned.

Qualifications:

Required
• Bachelor’s degree in Nursing
• 3-5 years Utilization Review or Case Management experience in hospital, clinic, insurance company, or long-term care facility.
• Minimum of 1-3 years of acute care hospital nursing experience.
• Current RN License

Preferred
• Minimum of 1-year Epic experience.
• Minimum 1-year experience using medical necessity screening criteria, such as InterQual or MCG.
• Minimum of 3-5 years of acute care hospital nursing experience.
• Excellent computer and database management skills.

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