Utilization Management Specialist (RN Required) - REMOTE

Discover Vanderbilt University Medical Center:  Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Organization:

Utilization Management 10

Job Summary:

JOB SUMMARY
Facilitates optimal reimbursement through accurate certification and complete chart documentation ensuring that the appropriate admission status is ordered. Conducts initial admission based on utilization review medical necessity criteria. Refers cases for secondary review when appropriate. Refers and consult with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.

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KEY RESPONSIBILITIES
• Facilitates optimal reimbursement through certification and denial processes.
• Facilitates throughput of patients admitted urgently or emergently through the emergency department.
• Participates as an active partner with multidisciplinary team members to ensure case is in the appropriate level of care setting.
• The responsibilities listed are a general overview of the position and additional duties may be assigned.

TECHNICAL CAPABILITIES
• Medical Terminology & Documentation (Novice): Possesses sufficient fundamental proficiency to successfully demonstrate medical terminology and documentation in practical applications of moderate difficulty.
• Clinical Applications Systems (Novice): Possesses fundamental proficiency in utilization review systems, clinical support systems and business support applications as needed
• Utilization Review (Intermediate): Demonstrates expertise of utilization review in practical applications of a difficult nature. Possesses sufficient knowledge, training, and experience to independently complete clinical review to obtain payor authorization. Demonstrates mastery in InterQual Level of Care Criteria and Milliam Care Guidelines. Able to train and educate by setting the example, giving technical instruction, providing leadership, and generally raising the level of performance of others while on the job.
• Interdisciplinary Education (Novice): Seeks to provide education by collaborating with providers and other members of the health care team to ensure that the patient is placed in the appropriate level of care setting.

 Our Nursing Philosophy:  

We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center’s mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being. 

As a Vanderbilt University Medical Center employee, you make a difference to our patients and their families by bringing compassion and care to those in need of hope and healing. Please see our current employee benefits offered:

• Affordable High Quality Health Plan Options
• Dental and /or vision plan
• 403 (b) retirement plan
• Paid Time off (flex PTO)
• Tuition Reimbursement and adoption assistance (maximums applied)
• Short-Long term disability
• Subsidized backup childcare
• And many more... Ask us about our current inpatient nursing supplemental Pay Program!

Achieve the Remarkable: 

Learn more about VUMC Nursing: 

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