RN Utilization Management

Summa Health

Akron (OH)

On-site

USD 78,000 - 117,000

Full time

3 days ago

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Job summary

Summa Health in Akron, OH is seeking an RN Utilization Management professional for a full-time shift 4:00pm–12:30am. The role focuses on cost-effective utilization across the care continuum, aligning with clinical outcomes and payer guidelines.

You will perform initial and concurrent reviews to obtain authorizations for acute care, collaborate with the Transitional Care Team and Physician Advisors, and support denial appeals and appeals with payers.

Qualifications

Associate's degree in Nursing (ADN) is required; BSN preferred.
Graduate of CCNE or ACEN accredited program.
Current Ohio RN license to practice.

Responsibilities

Perform initial and concurrent clinical reviews to capture authorization for acute care.
Collaborate with Transitional Care Team, Physician Advisors, Providers and department leadership to manage patient status.
Support appeal of payer denials in collaboration with internal RN teams and external advisers.

Skills

Clear communication

Data analysis

Independent work

Population care

Insurance industry knowledge

Education

Associate's degree in Nursing (ADN)

BSN preferred

CCNE/ACEN accredited program

Job description

Job Title

RN Utilization Management

Employment Type

Full-Time, 4:00pm-12:30am

Overview

Summa Health System is recognized as one of the region’s top employers by a number of third party organizations, including NorthCoast 99. Exceptional candidates gravitate to Summa because of its culture, passion for delivering excellent service to our patients and families commitment to our philosophy of servant leadership, collegial working relationships at every level of the organization and competitive pay and benefits.

Summary

Manages appropriate cost-effective utilization of services across the care continuum to align with improved clinical outcomes and lower costs. Demonstrates responsiveness to changing health care needs of the patient population and changes in insurance contracts and payment modalities such as bundled payments and shared risk arrangements. Performs initial and concurrent clinical reviews on all the contracted and emergent non-contracted patient encounters to capture authorization for acute care provided. Collaborates with Transitional Care Team, Physician Advisors, Providers and department leadership to effectively manage patient status (inpatient vs. observation) in the acute hospital setting per federal and payer guidelines through application of clinical criteria sets (MCG/InterQual) and compliance to federal guidelines (Medicare Two Midnight Rule). Supports Medicare patient right to appeal discharge in collaboration with QIO and Transitional Care team. Support appeal of payer denials through engagement of internal Physician Advisor, contracted physician advising service (Optum) and collaboration with formal denial appeal RN team.

Minimum Qualifications

Formal Education Required:
- Associate’s degree in Nursing (ADN) required, BSN preferred
- Graduate of a program of professional nursing that is accredited by the Commission on Collegiate Nursing Education (CCNE) or Accreditation Commission for Education in Nursing (ACEN)
- Current license to practice registered nursing in the State of Ohio
Experience & Training Required:
- Minimum of 2 years varied clinical experience in an acute care facility or having related experience in the Managed Health Care industry.
- Broad understanding of Utilization Management concepts that include, but are not limited to: Traditional Medicare and Medicaid Regulations and Requirements, Medicare Two Midnight Rule, Condition Code 44, Condition Code W2, Important Message From Medicare, HINN 12 Letters, Medicare Inpatient only Procedure List; Knowledge of Payer Types, Worker’s Compensation, Veteran’s Administration, DRG reimbursement, Outlier reimbursement agreements, Commercial insurance plan types: PPO, POS, HMO, Medicare Open Plans, Marketplace Plans, Carve out for Services, Indigent Plans, Institutional Accounts, ICD-10 codes.
Other Skills, Competencies and Qualifications:
- Demonstrate ability to communicate clearly, professionally, and confidentially
- Ability to analyze and use clinical outcome and aggregate data
- Demonstrate clinical expertise in patient population
- Ability to work independently to prioritize work and solve problems
- Population Specific Competency: Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity
- Broad understanding of insurance industry
Level of Physical Demands:
- Sedentary: Exerts up to ten pounds of force occasionally and/or a negligible amount of force frequently.

Equal Opportunity Statement

Equal Opportunity Employer/Veterans/Disabled

Salary

$37.40/hr - $56.11/hr

Salary Details

The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.

Benefits

Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits.