Overview Pay range: $47.35 - $71.03
Employer: ST. CHARLES HEALTH SYSTEM
Job title: RN Utilization Management
Reports to: Manager- Utilization Management
Department: Utilization Management
Date last reviewed: November 2024
Our vision: Creating Americas healthiest community, together
Our mission: In the spirit of love and compassion, better health, better care, better value
Our values: Accountability, Caring and Teamwork
Departmental summary: The Utilization Management (UM) Department promotes a centralized, collaborative multidisciplinary approach to utilization management across St. Charles Health System (SCHS). The UM Department supports physicians and clinical staff in identifying and improving care processes and systems for establishing and ensuring medical necessity, appropriate utilization of services, supporting denial avoidance and recovery and compliance with all local, state and federal regulations.
Position overview The Utilization Management Registered Nurse (RN) has well-developed knowledge and skills in utilization management, medical necessity and patient status determination. The UM RN supports the UM program by developing and maintaining effective and efficient processes for determining appropriate admission status based on regulatory and reimbursement requirements of various commercial and government payers. The UM RN performs a variety of concurrent and retrospective UM-related reviews and functions and ensures that appropriate data is tracked, evaluated and reported. When screening criteria do not align with the physician order or a status conflict is indicated, the UM RN escalates to the Physician Advisor or designated leader for review as determined by department standards. The UM RN uses denial avoidance strategies including concurrent payer communications to resolve status disputes. The UM RN monitors the effectiveness/outcomes of the UM program, identifies and applies metrics, evaluates data, reports results to various audiences and designs and implements process improvement projects as needed. This position does not directly manage any other caregivers.
Essential functions and duties Acts as an interdisciplinary team member within the UM Department; may provide cross-coverage for roles and responsibilities of other UM team members to back-fill during earned time off or backlogs due to peak volumes.
Performs pre-admission status recommendation review for multiple care settings (e.g., Emergency Department, Direct Admission/Transfer, elective procedures) and communicates status guidance to providers based on available information.
Ensures appropriate patient status upon admission and manages status conversions as appropriate.
Ensures completion of admission medical necessity reviews within 24 hours of admission.
Completes concurrent inpatient medical necessity reviews at least every three (3) days unless otherwise specified by payor.
Completes Observation medical necessity reviews at least every 12 hours (twice daily).
Completes Medicare extended stay reviews, as appropriate.
Assigns an initial working DRG & GMLOS upon completion of initial medical necessity review for IP admission and enters in EMR.
Completes discharge reviews and ensures completeness of all prior medical necessity reviews and authorizations; escalates concerns as appropriate.
Identifies and escalates all 1MN and 2MN Medicare IP stays.
Collaborates with Care Management (CM) team as appropriate (e.g., extended observation stays, patients no longer meeting medical necessity, status changes).
Collaborates with physicians as appropriate (e.g., to address issues concerning medical necessity, status orders, appropriate level of care, peer-to-peer involvement).
Collaborates with payors as appropriate (e.g., discuss status, changes in LOC, changes in pre-authorizations warranting reauthorization).
Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM), as appropriate.
Escalates Medical Necessity concerns to Physician Advisor or designated leader, as appropriate.
Assists with discharge appeal process, as appropriate.
Provides timely and continual coverage of assigned work area to ensure all accounts are complete.
Assists in identifying Avoidable Days and communicates information with CM, as appropriate.
Complies with all documentation requirements.
Follows up on action items prior to end of shift.
Maintains working knowledge of payor contracts and regulatory requirements and UM-specific changes (e.g., changes in authorizations, payor contracts, CMS, regulatory requirements).
Completes tasks within department guidelines and adheres to hospital policies, procedures, rules, regulations and laws.
Provides support regarding Medicare documentation requirements.
Obtains verbal admission orders from physicians and monitors for authorization by the physician.
Participates in the delivery of regulatory forms to patients when appropriate.
Communicates with insurance companies regarding medical necessity of admission and provides clinical documentation and reviews to insurance companies as requested for ongoing authorization of hospital stays.
Actively participates in clinical performance improvement activities.
Assists in collection and reporting of resource and financial indicators (LOS, cost per case, avoidable days, resource utilization, readmission rates, concurrent denials, appeals).
Supports the vision, mission and values of the organization in all respects.
Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement and acts as a change champion.
Provides and maintains a safe environment for caregivers, patients and guests.
Conducts activities with professionalism and confidentiality; complies with laws, regulations, policies, and procedures; supports corporate integrity and reports known or suspected violations.
Delivers customer service and/or patient care in a timely, efficient and accurate manner.
May perform additional duties of similar complexity within the organization, as required or assigned.
Education Required: Graduate of an accredited school of nursing.
Preferred: Bachelor’s degree in Nursing or Health Care related field
Licensure/Certification/Registration Required: Current Oregon RN license
Preferred: Accredited Case Manager Certification (ACMA:ACM-RN), Commission for Case Manager Certification (CCMC:CCM), Case Management Nurse-Board Certified (CMGT-BC:ANCC)
Experience Required: Three (3) years acute care clinical nursing experience
Preferred: Five (5) years clinical experience in an acute care facility
Two (2) years Utilization Management experience, or equivalent professional experience
Two (2) years experience working in electronic health records
Additional position information Skills: Advanced critical thinking and conflict resolution skills, working knowledge of regulatory and survey standards (Medicare, Joint Commission); working knowledge of status determination criteria (InterQual or MCG) and ability to apply consistently according to interrater reliability techniques; working knowledge of rapid-cycle process improvement
General: Ability to interact and communicate with all levels within SCHS and external customers/clients/potential employees; strong teamwork and collaboration; ability to multi-task and work independently; attention to detail; excellent organizational, written and oral communication and customer service skills; strong analytical, problem solving and decision-making skills; proficiency with electronic medical records and MS Office
Physical/Protective Equipment Personal Protective Equipment (PPE): Must be able to wear appropriate PPE required to perform the job safely.
Physical requirements Continually (75%+): Use of clear and audible speaking voice and ability to hear normal speech
Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation
Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing
Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle
Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech
Exposure to elemental factors: Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface
Blood-Borne Pathogen (BBP) exposure: No risk for BBP exposure
Schedule Weekly hours: 36
Caregiver type: Regular
Shift: First Shift (United States of America)
Is Exempt Position? No
Job family: NON CONTRACT RN SPECIALIST
Scheduled days of the week:
Shift Start & End Time: