RN, Utilization Management

University of Rochester; City of Rochester (NY); Hybrid; USD 81,000 - 110,000; Full time

Job summary

University of Rochester in Rochester, NY is seeking an RN for Utilization Management in a hybrid work setting. The role requires ensuring medical necessity and appropriate patient care levels, collaborating across departments, and supporting education and performance improvement within the health care system.

The candidate will review clinical documentation, determine level of care, coordinate with payers for authorization, monitor UM hold bills, and assist with discharge appeal processes.

Qualifications

• Associate's degree in Nursing with 3 years acute hospital experience required.
• BSN preferred; equivalent education/experience acceptable.
• NYS RN license required at hire.

Responsibilities

• Reviews clinical documentation to determine level of care using evidence-based criteria.
• Works with payers to obtain authorization for dates of service.
• Monitors UM hold bills and unplanned readmissions reports.
• Documents per regulatory guidelines and UM workflow protocols.
• Provides ongoing educational support for UM customers and improvements initiatives.
• Supports discharge appeal process and manages denials/appeals.

Skills

Interqual

Clinical documentation

Payer authorization

Educational support

Productivity

Education

Associate's degree in Nursing

Bachelor's degree in Nursing

Tools

Sharepoint

eRecord

ePARC

Cobius

Job description

## RN, Utilization ManagementApply: Hybrid: Strong Memorial Hospital: Full time: Posted Today: R274508As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.**Job Location (Full Address):**601 Elmwood Ave, Rochester, New York, United States of America, 14642**Opening:**Worker Subtype:RegularTime Type:Full timeScheduled Weekly Hours:40Department:500009 Utilization ManagementWork Shift:UR - Day (United States of America)Range:UR URCD 215Compensation Range:$81,307.00 - $109,761.00*The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.***Responsibilities:**Works collaboratively with various departments across the entire health care system to review clinical documentation, utilizing evidence based criteria to support medical necessity and appropriate level of patient care for services provided. Reports outcome trends and patterns to UM leadership to help identify educational opportunities and performance improvement initiatives across the health care continuum. Adapts to process changes and assists with education efforts that support ongoing improvement.**ESSENTIAL FUNCTIONS*** Determines level of care per regulatory requirements. Provides level of care notifications to patients and families as needed.* Works collaboratively with payers to ensure authorization for dates of service. Collaborates with HIM, providers, Financial Counseling and Patient Financial Services. Monitors all UM hold bills and unplanned readmission reports.* Conducts initial and concurrent reviews, utilizing evidence based criteria through Interqual. Supports discharge appeal process. Responsible for departmental denials and appeal activity.* Documents according to regulatory guidelines and UM RN workflow protocols. Conducts clinical documentation improvement efforts through query process.* Meets productivity expectations established by UM department.* Provides and supports ongoing educational needs for all UM customers.* Other duties as assigned.**MINIMUM EDUCATION & EXPERIENCE*** Associate's degree in Nursing and 3 years of acute hospital experience required* Bachelor's degree in Nursing (BSN) preferred* Or equivalent combination of education and experience* Utilization Management experience preferred**KNOWLEDGE, SKILLS AND ABILITIES*** Database experience including: Interqual, Sharepoint, eRecord, ePARC, Cobius preferred**LICENSES AND CERTIFICATIONS*** RN - Registered Nurse - State Licensure and/or Compact State Licensure NYS Registered Nurse license upon hire requiredThe University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.