Overview:
The RN Utilization Management Specialist, under the direction of the Manager, Utilization Management serves a key role in coordinating the organization’s interdisciplinary effort to assess and effectively use organizational resources and to track and minimize the inappropriate use of such resources.
Why UnityPoint Health? (Text Only): At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker’s Healthcare several years in a row for our commitment to our team members. Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. Here are just a few: – Expect paid time off, parental leave, 401K matching and an employee recognition program. – Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members. – Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family. With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together. And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. Find a fulfilling career and make a difference with UnityPoint Health. Responsibilities:
- Performs utilization management admission and continued stay outpatient reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources.
- Maximizes positive financial outcomes for patients and hospital by conducting timely ongoing chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care.
- Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making.
- Requests reviews with external and internal physician advisors as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status.
- Applies accepted potentially avoidable day logic to reviews so that accurate and timely data collection may occur.
- Serves as a resource to internal and external staff on issues related to utilization management
- Maintains current knowledge of Utilization Review Methodology, software, criteria and regulations governing various payment systems.
- Maintains current knowledge of the Unity Point Health Utilization Management Plan.
- Maintains current knowledge of CMS rules (e.g. Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement.
- Works with physicians regarding utilization issues as needed.
- Provides information to Denials staff as requested
Qualifications:
- Graduate of an accredited nursing program
- Preferred: BSN
- 2 years of nursing experience
- Registered Nurse – Licensed and registered in the appropriate state(s)
- Valid driver’s license when driving any vehicle for work-related reasons
- Professional communication – written & verbal
- Microsoft Office proficiency (Outlook, Word, Excel)
- Customer/patient focused
- Self-motivated
- Ability to work with minimal supervision
- Ability to manage priorities/deadlines
- Ability to multi-task and prioritize workload
- Flexible and adaptable to changing environment
- Excellent critical thinking and problem-solving skills
- Positive attitude with team-oriented approach
- Ability to give work direction to non-clinical staff
- Use of usual and customary equipment used to perform essential functions of the position.