RN - Utilization & Clinical Denial Management (Weekend)

Utilization Management Staff RN

Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of the Carle Foundation Hospital. Facilitates the care of patient by insuring that admissions and continued days are medically necessary, cost-effective, and provided in the appropriate level of care to qualify for reimbursement.

Qualifications:

• Certifications: Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• Education: College Diploma: Nursing; Associate's Degree: Nursing

Responsibilities:

• Function within the IP Care Coordination Department to ensure that the most cost-effective and appropriate use of health care services for patients treated by Carle Foundation Hospital.
• Ensures efficient patient flow and throughput
• Initial assessment of all new patients for correct status (admission/observation/outpatient) based on UR medical necessity criteria.
• Performs concurrent reviews of all patient charts to ensure proper resource utilization as necessary to identify practice trends.
• Keeping LOS within patients working DRG.
• Send clinical documentation to insurance companies per their request.
• Communicate with physicians on status changes and documentation.
• Refers cases for secondary review when appropriate.
• Refers cases for escalated medical review when services do not meet medical necessity criteria and/or appropriate level of care.
• Documents utilization reviews/issues in appropriate locations, including but not limited to case management/utilization review software.
• Track Avoidable days.
• Educates and assists physicians in resource utilization.
• Participate in extended care reviews and attend meetings.
• Review cases for potential quality indicators and refers to UM Leadership.
• Works with Appeal staff to actively appeal cases concurrently and retrospectively.
• Strong attention to detail is required, as to minimize any misunderstandings regarding services authorization of or denial of services.
• Possess a working knowledge of Carle's organization and IPCC operations and administrative standards and policies.
• Expert with acute level of care criteria.
• Apply severity of illness and intensity of service to determine appropriateness of care.
• Excellent interpersonal communication and the ability to interact with healthcare professionals in all disciplines.
• Ability to effectively communicate with physicians, payers, and hospital staff in a non-confrontational manner and provide excellent customer service.
• Ability to build rapport with medical staff, hospitalists services, and hospital leadership to obtain collaboration necessary to achieve desired UM outcomes.
• Strong data management and computer skills (Word, Excel. Outlook, and EPIC Case Management software).