RN - Utilization Management - Per Diem - Days - MSS

Memorial Healthcare

3d • Onsite

About The Position

The Utilization Management RN uses evidence-based medical necessity screening tools to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures, and an estimation of the patient’s expected length of stay. The Utilization Management RN follows the Utilization Review (UR) process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.

Requirements

• Accredited Program: Nursing (Required)
• Registered Nurse Compact License (RN LICENSE COMPACT) - Compact RN Multistate, Registered Nurse License (RN LICENSE) - State of Florida (FL)
• Requires critical thinking skills, effective communication skills, decisive judgment, and the ability to work with minimal supervision.
• Current sound clinical knowledge; knowledge of medical literature, research methodology, and financial/reimbursement issues.
• Knowledge of CMS, commercial payer requirements and hospital financial/reimbursement processes.
• Ability to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams.
• Must be able to work in a stressful environment and take appropriate action.
• Two (2) years of nursing experience.
• One (1) year of experience in utilization management or case management preferred.

Nice To Haves

• Certification in utilization management and/or case management preferred.

Responsibilities

• Manages timely communication of pertinent clinical data to support admission, clinical condition, and continued stays.
• Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement, and claim denials/appeals.
• Collaborates with onsite Case Management team regarding patient's discharge readiness.
• Prepares statistical analysis and utilization review reports as necessary.
• Reviews admissions and service requests for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.
• Uses medical necessity criteria and reviews medical records to determine patient’s medical necessity for acute hospitalization at the appropriate level of care.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: No Education Listed