Utilization Management RN - FT Days

Utilization Management Specialist

Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Performs denial and appeal activities for inpatient hospital care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.

Job Duties

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Collaborates with the Physician Advisor and members of the Multidisciplinary Team to facilitate the Case Management Condition 44 process.
• Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards.
• Performs appeal process in coordination with specific third party payor format, protocols, and timelines.

Minimum Qualifications

• Bachelor's Degree Nursing
• 3 years case management experience, discharge planning or utilization management experience required.
• Knowledge of managed care, governmental and third party payors reimbursement.
• Must be proficient with InterQual and mcg criteria and its application.
• Strong interpersonal relationships.
• Ability to: prioritize workload; collaborate with others to meet multiple deadlines; communicate effectively orally and in writing; work in a team environment, document in electronic health records.
• Knowledge of the medical, social, economic, and other services provided by other departments or facilities, and the ability to integrate these multidisciplinary treatments for optimal patient care.
• Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.
• Understands the impact of developmental stage on adjustment to illness/trauma.
• Demonstrates ability to identify adolescent behaviors concerning body image, independence, sexual identity, interference with ability to establish identity, tendency to deny or minimize severity of illness.
• Demonstrates understanding of end of life issues.
• Exhibits effective communication skills while working with neonate, infant, adolescent, and geriatric patient.
• Demonstrates ability to recognize the signs of physical and/or emotional abuse or neglect to help identify victims.
• Demonstrates the ability to identify hearing and sight deficiencies in geriatric population.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania
• RN - Licensed Registered Nurse_NJ - State of New Jersey