RN Utilization Management

Summa Health; Cleveland (OH); On-site; USD 78,000 - 117,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Life Insurance

Disability (short/long-term)

Retirement Savings Plan

Flexible Spending Accounts

Employee Assistance Program

Identity Theft Protection

Pet Insurance

Education Assistance

Daily Pay

Job summary

Summa Health System is seeking a Full-Time Utilization Management Nurse to optimize cost-effective care across the hospital care continuum. The role involves performing initial and concurrent reviews, aligning with Medicare/ payer guidelines, and applying clinical criteria to determine appropriate inpatient vs.

observation status. Responsibilities include collaborating with the Transitional Care Team and physician advisors, ensuring compliant discharge appeals, and supporting denial review

Qualifications

• ADN required; BSN preferred.
• Ohio RN license required.
• 2+ years acute care or managed care experience.

Responsibilities

• Perform initial and concurrent clinical reviews to authorize acute care services.
• Collaborate with Transitional Care Team, Physician Advisors, Providers and department leadership on patient status and criteria.
• Support appeals of payer denials with internal teams and external advisors.

Skills

Communication

Data analysis

Clinical expertise

Independent work

Population-specific care

Insurance knowledge

Education

RN-ADN

BSN preferred

Ohio RN license

CCNE/ACEN accredited program

Job description

Full-Time, 4:00pm-12:30am 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 Employer/Veterans/Disabled

$37.40/hr - $56.11/hr

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.

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

• Basic Life and Accidental Death & Dismemberment (AD&D)
• Supplemental Life and AD&D
• Dependent Life Insurance
• Short-Term and Long-Term Disability
• Accident Insurance, Hospital Indemnity, and Critical Illness
• Retirement Savings Plan
• Flexible Spending Accounts – Healthcare and Dependent Care
• Employee Assistance Program (EAP)
• Identity Theft Protection
• Pet Insurance
• Education Assistance
• Daily Pay