Utilization Review RN

Utilization Management Position

At MercyOne, health care is more than just a doctor's visit or a place to go when you need medical attention. Our Mission is based on improving the health of our communities that means not only when you are sick but keeping you well. MercyOne Central Iowa sets the standard for personalized and radically convenient care in the Des Moines metro area and surrounding counties. MercyOne Des Moines Medical Center, founded by the Sisters of Mercy in 1893, is the longest continually operating hospital in Des Moines and Iowa's largest medical center, with 802 beds available. The hospital is one of the Midwest's largest referral centers. With more than 7,000 colleagues and a medical staff of almost 1,500 physicians and allied health professionals, MercyOne Central Iowa is one of Iowa's largest employers.

General Requirements:

Responsible for the review of inpatient and outpatient admission records for appropriate admission status at Mercy Medical Center and Mercy West Lakes. Works in collaboration with the attending physician and the Case Management staff utilizing admission criteria guidelines-and second level physician review process when appropriate. Interacts with insurance providers to obtain authorization and continued stay approval for admission. Collaborates with the Verification department, Revenue cycle and Medical Eligibility to facilitate the establishment of the correct payer source for patient stay and the documentation of the interactions in the STAR admitting system.

Shift: Full-Time Days | Flexible Day Shift (7:00 AM 3:30 PM)

This UM position is On-Site in Des Moines, Iowa.

Essential Functions:

• Conducts admission review per the Utilization Management Plan to ensure that the hospitalization is approved based on established criteria. Reviewing may be both concurrent or post discharge.
• Carries out hospital programs and principles of utilization review in compliance with hospital policies and external regulatory agencies Peer Review Organization (PRO), Joint Commission, and multiple payer defined criteria for eligibility.
• Applies Milliman Careguidelines Criteria for appropriate status determination.
• Engages in discussion with the attending physician for clarification and/or status correction.
• Engages second level physician review as indicated to support the appropriate status.
• Ensures timely communication with Case Management staff for all concurrent status changes.
• Administers Notice of Status Change to the patient/family when indicated. Provides education and information for the patient/family for clarification of the change.
• Documents in the Medical Record Utilization Management forms accurately to reflect the appropriate admission criteria and appropriate status along with any communications.
• Collaborates with MercyOne Post Denials team to determine potential appeals or downgrades and documents in STAR.
• Ensures timely notification to Admitting of status of change or status discrepancies identified.
• Reviews the records on admission for status orders present addressing Center for Medicare Services rules and guidelines around admission status.
• Monitors insurance coverage for patients in the STAR admitting/financial system and communicates any updates to the Verification Department.
• Provides clinical information as request from the insurance payer via the query, fax or portal in a timely manner to prevent technical denials.
• Enters authorization, approvals and denials into the STAR systems and communicates pertinent changes to Case Management.
• Engages the attending physician to advocate and communicate via Peer to Peer Review for discussion with insurance for admission, continued stay or status when required.
• Reviews denial letters/faxes received in Care Coordination Department and direct to Conifer Appeal Department for appeal. Documents in the STAR system.
• Collaborates in monitoring and addressing observation outliers and status discrepancies with Medical Records Department and Admitting Department.
• Collaborates with the Recovery Audit Contractor (RAC) Coordinator and Conifer for Medicare/Medicaid RAC Denials management.

Marginal Functions:

General office duties of filing, data retrieval and computer use.

Minimum Knowledge, Skills and Abilities Required:

• Current licensure as a registered nurse in the State of Iowa.
• Five (5) years clinical nursing experience.
• Bachelor of Science - Nursing or degree in healthcare-related field preferred.
• Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire.
• Knowledge of eligibility requirements for insurance coverage with respect to health care services: ambulatory, observation stays, surgical, acute care, subacute and continuum of care services.
• Demonstrated ability to manage complex management and clinical situations. Ability to work within a function independently exercising judgement to reach resolutions to issues.
• Specialty certification in Utilization Review within 12 months of hire preferred.

Colleagues of MercyOne Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout the system!