Registered Nurse (RN) - Utilization Management Nurse

Job Title: Registered Nurse I

Department: Utilization Management                     

Location:  Rochester General Hospital                         

Hours Per Week: 40 hours (Full-Time)

Schedule:  Monday - Friday, Days                        

                

SUMMARY:

Review all inpatient medical necessity denials for the health system based on InterQual and/or CMS guidelines. Responsibilities include managing the workflow with the standard UM sources for potential inpatient medical necessity denials. Assists and guides the Center Business Office with any billing issues involving inpatient medical necessity patient class as needed. Responsibilities include concurrent (as needed) and retrospective reviews. The Utilization Management Nurse will act as a resource on denial management as needed across the organization.

RESPONSIBILITIES:

• Review standard UM sources for potential inpatient medical necessity denials. Review patient class in the event manager, assist with LOC determination retrospectively, and changes patient class as it relates to the Provider order for billing purposes.

• Meet all appeal deadlines for all payers. Demonstrates fiscal responsibility.

• Prepare the UM review findings, initiate and 1st, 2nd, and/or arbitration appeals as needed. Document in all areas that an appeal has been initiated or no appeal is necessary per UM reviews.

• Track and monitor all denials, appeals, arbitration responses to payers/audits.

• Participates in periodic denial meetings with Physician Advisors to review the denials that do not meet InterQual and/or CMS guidelines for his/her recommendation regarding appeal options.

• Manages confidential information in accordance with RRH policy and procedures.

• Retrospectively communicates clinical information to payers, severity of illness, and intensity of service and plan of care.

• Maintains accountability to hospital, state, and federal regulations, and professional standards. Initiates alternate level of care determinations in compliance with regulatory and contractual agreements.

• Actively participates in Education sessions.

• Actively participates in analysis of utilization and quality trends and makes recommendations to management on opportunities for improvement.

• Using nationally recognized standards of care and guidelines.

• Prioritizes multiple projects and tasks. Be able to work independently with minimum direction.

• Act as a resource for utilization review stakeholders and assists team members in clinical problem solving.

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REQUIRED QUALIFICATIONS:

• 3 years of acute hospital care, Case Management and/or Utilization Management experience

• Excellent oral and written communication and interpersonal skills

• Good understanding of medical management techniques and processes

• Strong organizational and problem solving skills

• Electronic Medical Record experience (Epic)

• Able to adapt and be flexible to changes based on health system needs

• Current New York State Registered Nurse License

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PREFERRED QUALIFICATIONS:

• BS degree

• Knowledge of Federal and State regulations (DOH, Medicaid/Medicare)

• Knowledge of third party payer and/or managed care payment principles helpful

• Case Management Certification

• At least 3 years RN experience preferred

EDUCATION:

BS (Required)

LICENSES / CERTIFICATIONS: 

BLS - Basic Life Support - American Heart Association (AHA)American Heart Association (AHA), RN - Registered Nurse - New York State Education Department (NYSED)New York State Education Department (NYSED)

PHYSICAL REQUIREMENTS:

M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expec