Utilization Management Nurse II - Surgical

Medical University of South Carolina

1d

About The Position

The Utilization Management Nurse (UMN) reports to the Manager of Case Management and Care Transitions. Under general guidance of the Nurse Case Manager Team Leader of the Service Line, the UM Nurse functions as a member of the clinical service line team facilitates optimal reimbursement through accurate certification of their assigned patients. This position conducts initial admission reviews and refers cases for secondary review when appropriate. This role ensures the adherence to regulatory requirements with Medicare, FFS Medicaid, and other government payers. The UM Nurse refers and consults with the multidisciplinary team to promote appropriate communication of the review results to hospital revenue professionals to ensure proper utilization of hospital resources for accurate reimbursement Entity Medical University Hospital Authority (MUHA)

Requirements

• Bachelor's degree in Nursing from an accredited school of nursing and five years of nursing work experience to include two years utilization / case management experience in a hospital setting required.
• Licensure as a registered nurse by the state of South Carolina or compact state required.
• Must possess excellent verbal and written communication skills.

Nice To Haves

• Prior leadership experience preferred.
• Evidence of committee involvement within a healthcare setting needed (either departmental or hospital-wide).
• Familiarity with InterQual and/or MCG screening criteria desired.

Responsibilities

• Conducts utilization reviews to determine if patients are receiving care appropriate to severity of illness or condition and intensity of services required.
• Monitors patient charts and records to evaluate care concurrent with the patients treatment.
• Reviews treatment plans and status of approvals from insurers.
• Collects and complies data as required and according to applicable policies and regulations.
• Consults with providers and other stakeholders as needed.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level