Utilization Review- RN

Utilization Review—RN US–Remote Requisition ID: 2026-39874 Position Category: Nursing – Care Management Job Type: ONA union represented Position Type: Regular Part-Time Posting Department: Utilization Review Posting Salary Range: $55.24–$92.02 per hour, based on experience, education and internal equity Posting FTE: 0.60 Posting Schedule: variable M–F & every other weekend Posting Hours: 7am–3:30pm HR Mission: Healthcare Drug Testable: Yes Department Overview The Utilization Management Department enacts the hospital UR Plan. The department provides for the assessment of the medical necessity of admission and continued stay, appropriate bed status, denials management, and outlier review. The department provides clinical information to third party payers to assure medical necessity requirements are met to secure authorization. Benefits Comprehensive health care plans. Covered at 100% of the cost for full-time employees and 88% for dependents. $50K of term life insurance provided at no cost to the employee Two separate above market pension plans to choose from Vacation - 192 to 288 hours per year depending on length of service, prorated for part-time Holidays – up to 64 holiday hours per calendar year (employees accrue 0.0308 holiday hours for each hour paid – included in vacation accruals) Sick Leave – 96 hours per year, prorated for part-time Substantial public transportation discounts (Tri‑met and C‑Tran) Tuition Reimbursement Innovative Employee Assistance Program (EAP) including extensive wellness resources Function/Duties of Position Utilization Management Nurses work within the multidisciplinary team to determine medical necessity of admission and continued stay in the hospital as well as correct patient classification and efficient use of resources. They conduct robust utilization review. Utilization Management Nurses use established criteria to determine appropriateness of admission and continued stay and work with payers to assure ongoing authorization for continued stay. They contribute to meeting OHSU’s strategic plan of safe LOS reduction and reduction in readmission rates. Specifically, the UM Nurse does the following: Reviews pre‑admissions for correct classification and admission order. Performs utilization review for each patient on their assigned daily census using established medical necessity guidelines. Communicates with payers regarding authorization and medical necessity, utilizing excellent negotiating skills. Reviews order/classification discrepancies and takes actions to resolve the discrepancy. Discusses cases with providers and Case Managers as needed, including attending physicians and escalation to the Care Management Physician Advisor when indicated. Assesses for and tracks potentially avoidable hospital days. Assesses for and records reasons for readmissions. Participates in and supports strategic initiatives to reduce readmissions and LOS. Attends and contributes to outlier review rounds on an ad hoc basis. Provides education regarding utilization management issues to the multidisciplinary team. Prepares and conducts presentations, as assigned, to their assigned physician groups regarding issues related to utilization management in conjunction with the Care Management Physician Advisor. Educates providers regarding documentation requirements that support medical necessity determinations. Prepares and presents reports as requested by UM management. Facilitates MD Advisor to payer discussions. Assesses whether there is a basis for written appeal for cases in which payment is denied due to medical necessity concerns. Seek input from attending physicians and physician advisor as needed. Composes persuasive and grammatically correct written appeals for claims denied by payers for lack of medical necessity whether denied pre or post payment. This may include denials through retrospective audits by payers or through government audits. Presents case studies illustrating systems issues that adversely affect LOS and/or readmission rates to the Clinical Resource Management Committee and the Care Management Department. Serves as member of department and/or hospital committees and task forces working on issues related to utilization management, as assigned. Delivers Condition Code 44 notices, Observation notices (MOON), and Medicare Important Messages (IMM) in the absence of sufficient clerical support. Educates patients about their classification and financial implications as needed. Communicates in writing with attending physicians about UR committee cases. Facilitates utilization review case reviews in accordance with Medicare Conditions of Participation: Utilization Review. Coordinates and processes Medicare discharge appeals along with clerical support. Conducts secondary reviews for peers, assessing appropriate classification and medical necessity. Communicates closely with the multidisciplinary team about patients’ expected hospital course, expected discharge date, GMLOS, and authorization status. Communicates status upgrades and downgrades with the Bed Flow Manager. Documents according to departmental policy. Works with coding, patient business services, surgery schedulers, registration, and integrity department to determine correct billing and coding status for complex cases and assure correct classification. Provides feedback to managed care contracting regarding insurance company billing policies and practices that adversely affect OHSU’s ability to collect proper reimbursement for care provided. Leads the effort to assure compliance with CMS and other insurance regulations related to utilization review. Maintains current knowledge of, and complies with regulatory requirements of DNV, Medicaid, Medicare, CMS, applicable state regulations and Oregon Nurse Practice Act. Other UM activities as assigned. Department Specific Working Conditions Utilization Management follows patients on every inpatient, observation, and overnight day stay unit and the Emergency department. Some work occurs in support of procedural areas as well. Each Utilization Management Nurse has access to a computer workstation as this is a teleworking position. There is heavy frequent use of computers and telephones. Proficiency in the use of Microsoft Office: Word – create documents or outlines that may include use of tables, bullets, headers, footers, and basic formatting. Excel – ability to create and use basic spreadsheets that do not involve formulas or pivot tables. PowerPoint – ability to create basic presentations in outline form using approved OHSU graphics. Proficient at creating formal presentations and presenting to groups of medical professionals. Demonstrated proficiency with conflict resolution. Demonstrated proficiency working cooperatively and productively to achieve shared goals as a member of a team. Excellent written communication skills, including demonstrated ability to compose persuasive and grammatically correct written arguments. Excellent verbal communication skills. Successful experience in a leadership role in the past 10 years (e.g., charge nurse, nurse manager, UBNPC chair, group facilitator, hospital-wide committee membership). Proficiency within the interdisciplinary team in resolving conflicts, communicating and educating physicians on patient status decisions and other issues related to utilization management. Proficient in use of Interqual or MCG criteria. Understanding of the CMS rules and regulations. Ability and willingness to do presentations to groups of physicians and hospital leadership. Demonstrated ability to work independently with a minimum of supervision while meeting performance targets. Required Qualifications Three years of UM/UR experience required. BSN graduates: Baccalaureate Degree in Nursing from a program accredited by CCNE, ACEN or CNEA 30 days before start date. ADN graduates: Associate Degree in Nursing from an accredited program 30 days before the start date. Associate degree nurses required to enroll in BSN program within 3 years of hire and complete within 5 years of hire. Current, unencumbered Oregon State Registered Nurse license. BLS from AHA required. New hires will be enrolled and required to complete during orientation. Must be able to perform the essential functions of the position with or without accommodation. Preferred Qualifications Case Management Certification (ACM‑RN, RN‑BC, CCM, CGS, etc.) preferred. Knowledge of MCG, Indicia guidelines preferred. Additional Details Length of Orientation – Experienced Nurse External candidates: OHSU & Nursing New Employee Orientation (NEO) for about a week. Either Transition to Practice (TTP) Program Specialty Fellowship/Fellowship Learning Pathway or Orientation experience for 3 days–26 weeks depending on the care area. An employment service agreement may apply. Equal employment opportunity, including veterans and individuals with disabilities. #J-18808-Ljbffr Oregon Health & Science University