Care Management RN - Full-time

Schedule: Full-time days- Monday through Friday with shared rotating weekends.

Do you want to work in a culture where interdisciplinary teams come together to improve care, where your suggestions are welcomed and your ideas are part of the solution? UR/CDS Nurse Responsibilities:

Perform extensive record review in accordance with state regulations, ensuring compliance with changes affecting Utilization Management and Clinical Documentation Improvement.

Assess the appropriateness and medical necessity of treatment requests on a prospective, concurrent, and retrospective basis.

Interact frequently with providers, HIM professionals, social workers, nursing staff, patients and caregivers, and insurance companies.

Review medical records to improve clinical documentation, representing the severity of illness, risk of mortality, and patient complexity.

Perform utilization review in accordance with state regulations, ensuring compliance with changes affecting Utilization Management.

Assess the appropriateness and medical necessity of treatment requests for utilization review on a prospective, concurrent, and retrospective basis.

Review patient records and evaluate progress, obtaining necessary medical reports and treatment plan requests.

Review medical records to improve the quality of clinical documentation, representing the severity of illness, risk of mortality, and patient complexity.

Work with medical staff, case management, social work, clinical quality, and interdisciplinary care team to ensure quality patient outcomes through appropriate utilization of hospital resources.

Collect, analyze, and maintain data on the utilization of medical services and resources to identify trends and opportunities for improvement.

Serve as primary contact for Utilization Management related issues, both internally and externally.

Assess quality and clinical risk issues on a concurrent basis, reporting quality of care issues as identified.

Provide education to medical staff, department leaders, medical offices, and associates on Utilization Management principles, including the use of InterQual & Milliman criteria and CMS regulations.

Actively participate in committees and workgroups related to Utilization Management, Length of Stay Management, Readmissions and Observation services.

Collaborate and assist the manager in executing a Quality and Safety model, integrating regulatory mandates, and providing training for JC readiness.

Participate in team meetings and staff education in the Utilization Management process and Clinical Documentation Improvement Program.

Utilization Management principles including knowledge of various regulatory and payer specific requirements.

Clinical Knowledge: Proficiency in clinical criteria and understanding of medical treatments and interventions.

Critical Thinking: Ability to assess the appropriateness and medical necessity of treatment requests.

Regulatory Awareness: Effective interaction with providers, HIM professionals, social workers, nursing staff, patients, caregivers, and insurance companies.

Analytical Skills: Ability to collect, analyze, and maintain data on the utilization of medical services and resources.

Prioritize tasks effectively to manage multiple responsibilities and deadlines.

Adapt to changing situations and regulatory requirements in the healthcare environment.

Ensuring patients receive appropriate and cost‑effective healthcare services.

Working effectively with interdisciplinary teams to ensure quality patient outcomes.

Staying up to date with changes in healthcare regulations and best practices.

Registered Nurse in NYS

A.S. in Nursing

S. in Nursing or other health‑related field or willingness to get one within 5 years of employment.

Minimum 5 years of acute nursing experience.

Experience working with physicians in a collaborative supportive manner.

Knowledgeable in reimbursement methodologies & interpretation of payer contracts or willingness to learn.

Experience with computer applications including Microsoft Office.

Preferred experience with Epic.

Preferred experience in writing effective appeal letters.

Keeps abreast of complex and changing regulatory environment.

Effectively manages denials / appeals with attention to detail and follow‑up.

Thompson Health is an EOE encouraging individuals with disabilities and veterans to apply

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities