Utilization Management Nurse II

Job Summary/Purpose Conducts utilization reviews to determine if patients are receiving care appropriate to severity of illness or condition and intensity of services required. Monitors patient charts and records to evaluate care concurrent with the patient’s treatment. Reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Consults with providers and other stakeholders as needed. Responsibilities Conduct utilization reviews for initial admissions and refer cases for secondary review when appropriate. Ensure adherence to regulatory requirements with Medicare, FFS Medicaid, and other government payers. Act as a member of the clinical service line team to facilitate optimal reimbursement through accurate certification of assigned patients. Refer and consult with the multidisciplinary team to promote appropriate communication of the review results to hospital revenue professionals to ensure proper utilization of hospital resources for accurate reimbursement. Minimum Training and Education Bachelor's degree in Nursing from an accredited school of nursing and five years of nursing work experience, including two years of utilization / case management experience in a hospital setting. Prior leadership experience preferred. Evidence of committee involvement within a healthcare setting needed (either departmental or hospital-wide). Excellent verbal and written communication skills. Familiarity with InterQual and/or MCG screening criteria desired. Required Licensure, Certifications, Registrations Licensure as a registered nurse by the state of South Carolina or compact state required. Physical Requirements Ability to perform job functions while standing, sitting, walking, climbing stairs, working indoors, and from elevated and confined/cramped spaces. Must be able to lift and carry up to 50 lbs unassisted, lift/carry patients up to 350 lbs (+/-) assisted, lift objects from floor level to a height of 36 inches, lower objects, push/pull objects up to 350 lbs (+/-) unassisted. Maintain 20/40 vision corrected; ability to maintain hearing acuity and understand whispered conversations. Must be capable of performing gross motor functions with frequent fine motor movements. Be qualified physically (by medical personnel) for respirator use initially and annually. Ability to deal effectively with stressful situations, and possess computer literacy to work rotating shifts and learn new processes and tools. Work Schedule 40 scheduled weekly hours, Days shift, Salaried status. EEO Statement The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need. E-Verify Program Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please visit Entity Medical University Hospital Authority (MUHA) Position Details Worker Type: Employee, Worker Sub-Type: Regular, Pay Grade: Health-28, Pay Rate Type: Salary, Cost Center: CC005339 SYS - Utilization Management. #J-18808-Ljbffr