Utilization Management RN

GENERAL SUMMARY:

Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient's hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient's hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient's and hospitals financial well-being.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Performs utilization review activities, including concurrent and retrospective reviews as required.

3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria.

4. *Collaborates with the patient's provider and other healthcare team members in managing the patient's length of stay and determining the continuing medical necessity of continued stays.

5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm.

6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up.

7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay.

EDUCATION AND EXPERIENCE:

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.