RN Utilization Management: Drive Care Quality & Compliance

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

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.