RN - Utilization Management Analyst
About The Position
MU Health Care is looking for a Utilization Management Analyst RN to join our team. The ideal candidate will possess exceptional communication skills, the ability to collaborate effectively with healthcare teams, and a deep understanding of government and private insurance payer guidelines. Your role will involve overseeing patient admissions, conducting reviews, and ensuring that care is medically necessary and efficient. You'll play a vital role in maximizing reimbursements for hospital services, all while advocating for patients and educating both staff and physicians on utilization issues. Join us in making a difference in healthcare while enhancing your clinical expertise and critical thinking skills. This is more than a job; it's a chance to shape the future of healthcare at MU Health Care. ABOUT MU HEALTH CARE MU Health Care is proud to be named one of Forbes’ Best-in-State Employers seven years in a row, and that’s largely a result of the incredible culture and team we’ve built. At MU Health Care, we have an inspired, hard-working and collaborative environment driven by our mission to save and improve lives. Here, we believe anything is possible and rally around solutions. We celebrate innovation and offer opportunities to be a part of something bigger — to have a voice and role in the work that is serving our community and changing the field of medicine. Our academic health system — the only in mid-Missouri — is home to seven hospitals, including the region’s only Level 1 Trauma Center and region’s only Children’s Hospital, as well as over 90 specialty clinics. Here you can define your career among our many clinical and nonclinical positions — with growth, opportunity and support every step of the way. Learn more about MU Health Care. Learn more about living in mid-Missouri. EMPLOYEE BENEFITS · Health, vision and dental insurance coverage starting day one · Generous paid leave and paid time off, including nine holidays · Multiple retirement options, including 100% matching up to 8% and full vesting in three years · Tuition assistance for employees (75%) and immediate family members (50%) · Discounts on cell phone plans, rental cars, gyms, hotels and more · See a comprehensive list of benefits here.
Requirements
- Excellent written and verbal communication skills.
- Knowledge of government and private insurance payer guidelines and regulations.
- Knowledge in the application of InterQual and/or Milliman Criteria.
- Missouri Board of Nursing RN or Nurse Licensure Compact multi-state RN. When primary state of residency changes, compact state RNs must apply under new state of residency within thirty (30) days.
- Two (2) years of hospital clinical experience or two (2) years of current utilization review experience.
Nice To Haves
- Experience in tertiary care and/or a teaching hospital.
- Experience in conflict resolution strongly desired.
- Additional license/certification requirements as determined by the hiring department.
Responsibilities
- Monitor unscheduled admissions to ensure appropriate patient type, timely notification of payor, and identify appropriate target LOS.
- Pre-certify/preauthorize process as assigned.
- Monitor 23-hour observation to ensure conversion to inpatient status if appropriate or discharge.
- Assist with denial and appeal process. Document avoidable delays/days.
- Monitor and develop plans of action for patients with extended LOS over that allowed by the benefit plan.
- Monitor admissions according to all third-party criteria.
- Perform retrospective reviews as necessary.
- Collaborate with payor reviewers to ensure appropriate utilization of resources.
- Provide formal and informal education/in-services to staff and physicians on utilization issues.
- Assist with the development/revision of policies, procedures, and service standards.
- Participate in ongoing efforts to improve the utilization management process and CQI activities as assigned.
- Maintain current knowledge of payor criteria/policies related to utilization of resources.
- Audit charts per request of Patient Accounts and Revenue Recovery. Compile data and statistics for monthly and annual reporting.
- Maintain clinical expertise in Medical-Surgical, Pediatric, and Psychiatric clinical care. Escalate payer issues to attending physicians and hospital leadership.
- Actively collaborates with the health care team regarding the course of care delivery to ensure timely discharge. Serve as liaison between the payer and the physician.
- Utilize medical discernment and critical thinking skills on a case-by-case basis as required for reimbursement maximization.
- Participate in formal education of payer criteria policies to medical students and Residents.
- May complete unit/department specific duties and expectations as outlined in department documents.
Benefits
- Health, vision and dental insurance coverage starting day one
- Generous paid leave and paid time off, including nine holidays
- Multiple retirement options, including 100% matching up to 8% and full vesting in three years
- Tuition assistance for employees (75%) and immediate family members (50%)
- Discounts on cell phone plans, rental cars, gyms, hotels and more
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
