RN - Utilization Management Analyst Nurse

MU Health Care; Columbia Township (MO); Hybrid; USD 68,000 - 100,000; Full time

Benefits offered by this job

Health insurance

Paid time off

Retirement options

Tuition assistance

Discounts on services

Job summary

MU Health Care is seeking a Utilization Management Analyst RN to oversee patient admissions, reviews, and ensure medical necessity and efficient care. The role emphasizes maximizing reimbursements while advocating for patients, educating staff and physicians on utilization issues.

The position is hybrid with on-site requirements about once per month, located in Mid-M Missouri within MU Health Care's academic health system. Bonafide nursing licensure and UR experience preferred.

Qualifications

• Missouri RN license required.
• 2 years hospital clinical or utilization review experience.
• Knowledge of government and private payer guidelines.

Responsibilities

• Monitor admissions and ensure appropriate patient type.
• Pre-certify/preauthorize as assigned.
• Monitor 23-hour observation and conversion to inpatient status.
• Assist with denial and appeal processes and document delays.
• Collaborate with payor reviewers to ensure utilization of resources.
• Provide education to staff and physicians on utilization issues.
• Maintain knowledge of payor criteria and policies.

Skills

Communication

Team collaboration

Payer guidelines

Education

RN license

Tools

InterQual

Milliman Criteria

Job description

Shift:4 10-hour shifts including Saturday & Sunday. 7am - 5pm

Work Arrangement:Hybrid - on-site required approximately once per month

Department: Utilization Management

Facility: Quarterdeck Building (2401 Lemone Industrial Blvd, Columbia MO) or Capital Region Medical Center (1125 Madison ST, Jefferson City MO)

* Base Pay Range: $68,265 - $100,401 per year, based on experience

ABOUT THE JOB

MU Health Care is looking for a Utilization Management Analyst RN to join our team. The ideal candidate will possess exceptional communication skills, the ability to collaborate effectively with healthcare teams, and a deep understanding of government and private insurance payer guidelines. Your role will involve overseeing patient admissions, conducting reviews, and ensuring that care is medically necessary and efficient. You'll play a vital role in maximizing reimbursements for hospital services, all while advocating for patients and educating both staff and physicians on utilization issues. Join us in making a difference in healthcare while enhancing your clinical expertise and critical thinking skills. This is more than a job; it's a chance to shape the future of healthcare at MU Health Care.

ABOUT MU HEALTH CARE

MU Health Care is proud to be named one of Forbes' Best-in-State Employers seven years in a row, and that's largely a result of the incredible culture and team we've built. At MU Health Care, we have an inspired, hard-working and collaborative environment driven by our mission to save and improve lives. Here, we believe anything is possible and rally around solutions. We celebrate innovation and offer opportunities to be a part of something bigger - to have a voice and role in the work that is serving our community and changing the field of medicine.

Our academic health system - the only in mid-Missouri - is home to seven hospitals, including the region's only Level 1 Trauma Center and region's only Children's Hospital, as well as over 90 specialty clinics. Here you can define your career among our many clinical and nonclinical positions - with growth, opportunity and support every step of the way.

Learn more about MU Health Care.

Learn more about living in mid-Missouri.

EMPLOYEE BENEFITS

• Health, vision and dental insurance coverage starting day one
• Generous paid leave and paid time off, including ten holidays
• Multiple retirement options, including 100% matching up to 8%and full vesting in three years
• Tuition assistance for employees (75%) and immediate family members (50%)
• Discounts on cell phone plans, rental cars, gyms, hotels and more

See a comprehensive list of benefits here.

DETAILED JOB DESCRIPTION

• Monitor unscheduled admissions to ensure appropriate patient type, timely notification of payor, and identify appropriate target LOS.
• Pre-certify/preauthorize process as assigned.
• Monitor 23-hour observation to ensure conversion to inpatient status if appropriate or discharge.
• Assist with denial and appeal process. Document avoidable delays/days.
• Monitor and develop plans of action for patients with extended LOS over that allowed by the benefit plan.
• Monitor admissions according to all third-party criteria.
• Perform retrospective reviews as necessary.
• Collaborate with payor reviewers to ensure appropriate utilization of resources.
• Provide formal and informal education/in-services to staff and physicians on utilization issues.
• Assist with the development/revision of policies, procedures, and service standards.
• Participate in ongoing efforts to improve the utilization management process and CQI activities as assigned.
• Maintain current knowledge of payor criteria/policies related to utilization of resources.
• Audit charts per request of Patient Accounts and Revenue Recovery. Compile data and statistics for monthly and annual reporting.
• Maintain clinical expertise in Medical‑Surgical, Pediatric, and Psychiatric clinical care. Escalate payer issues to attending physicians and hospital leadership.
• Actively collaborates with the health care team regarding the course of care delivery to ensure timely discharge. Serve as liaison between the payer and the physician.
• Utilize medical discernment and critical thinking skills on a case‑by‑case basis as required for reimbursement maximization.
• Participate in formal education of payer criteria policies to medical students and Residents.
• May complete unit/department specific duties and expectations as outlined in department documents.

KNOWLEDGE, SKILLS, AND ABILITIES

• Excellent written and verbal communication skills.
• Knowledge of government and private insurance payer guidelines and regulations.
• Knowledge in the application of InterQual and/or Milliman Criteria.

REQUIRED QUALIFICATIONS

• Missouri Board of Nursing RN or Nurse Licensure Compact multi‑state RN. When primary state of residency changes, compact state RNs must apply under new state of residency within thirty (30) days.
• Two (2) years of hospital clinical experience or two (2) years of current utilization review experience.

PREFERRED QUALIFICATIONS

• Experience in tertiary care and/or a teaching hospital.
• Experience in conflict resolution strongly desired.
• Additional license/certification requirements as determined by the hiring department.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. The employee may be required ambulate, remain in a stationary position and position self to reach and/or move objects above the shoulders and below the knees. The employee may be required to move objects up to 10 lbs.

Equal Employment Opportunity

The University of Missouri is an Equal Opportunity Employer.