RN Utilization Management (Relief)

St. Charles Health System; United States; Remote; USD 10,000 - 60,000; Full time

Job summary

A health care organization in the United States is seeking an RN Utilization Management to develop processes for admission status determination and perform utilization management reviews. The ideal candidate will have an Oregon RN license and three years of acute care nursing experience, including knowledge of regulatory standards. This full-time position offers competitive pay and opportunities for growth within a collaborative environment.

Qualifications

• Current Oregon RN license required.
• Three years acute care clinical nursing experience required.
• Utilization Management experience preferred.

Responsibilities

• Develop and maintain processes for determining admission status.
• Perform concurrent and retrospective UM reviews.
• Collaborate with physicians and care management.

Skills

Advanced critical thinking

Conflict resolution

Knowledge of regulatory standards

Customer service

Education

Graduate of an accredited school of nursing

Bachelor’s degree in Nursing or Health Care related field

Job description

Overview

Pay range: $47.35 - $71.03

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: RN Utilization Management

REPORTS TO POSITION: Manager- Utilization Management

DEPARTMENT: Utilization Management

DATE LAST REVIEWED: November 2024

OUR VISION: Creating America’s healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

DEPARTMENTAL SUMMARY: The Utilization Management (UM) Department promotes and provides a centralized, collaborative multi-disciplinary approach to utilization management across St. Charles Health System (SCHS). The UM Department supports physicians and clinical staff in identifying and improving care processes and systems for establishing and ensuring medical necessity, appropriate utilization of services, supporting denial avoidance and recovery and compliance with all local, state and federal regulations.

Responsibilities

• Position Overview: The Utilization Management Registered Nurse (RN) has knowledge and skills in utilization management, medical necessity and patient status determination. The UM RN supports the UM program by developing and/or maintaining effective processes for determining appropriate admission status based on regulatory and reimbursement requirements of various payers. The UM RN performs concurrent and retrospective UM reviews and ensures data is tracked, evaluated and reported. When screening criteria do not align with physician orders or a status conflict is indicated, escalate to the Physician Advisor or designated leader as determined by department standards. The UM RN also implements denial avoidance strategies including concurrent payer communications to resolve status disputes. Additionally, the UM RN monitors UM program effectiveness/outcomes, applying metrics, evaluating data, reporting results, and designing/improving processes as needed.
• Escalation and Collaboration: Escalate Medical Necessity (patient status / LOC) concerns to Physician Advisor or designated leader as appropriate. Collaborate with Care Management, physicians, payors, Patient Access, PFS and HIM as appropriate. Assist with the discharge appeal process when needed.
• Program Impact: Identify and apply improvements, and assist in collection and reporting of resource and financial indicators (LOS, cost per case, avoidable days, readmission rates, etc.).
• Coverage and Compliance: Provide timely coverage of assigned work area and ensure all accounts are complete; maintain knowledge of payor contracts and regulatory requirements and UM changes.
• Operations: Ensure admission medical necessity reviews are completed within 24 hours of admission; complete concurrent inpatient reviews at least every 3 days and Observation reviews at least every 12 hours; assign initial DRG/GMLOS upon initial review and document in EMR; complete discharge reviews and ensure prior reviews/authorizations are complete; collaborate with CM and physicians on medical necessity and level of care issues; maintain and escalate as needed.

This position does not directly manage any other caregivers.

Essential Functions and Duties

• Acts as an interdisciplinary team member within the UM Department and may provide cross-coverage for other UM team members during earned time off or peak volumes.
• Performs pre-admission status recommendation reviews for multiple settings (ED, direct admissions/transfers, elective procedures) and communicates status guidance to providers.
• Ensures appropriate patient status upon admission and manages status conversions as appropriate.
• Completes admission medical necessity reviews within 24 hours of admission.
• Completes concurrent inpatient medical necessity reviews at a minimum of every three (3) days; Observations reviews at a minimum of every 12 hours; Medicare extended stay reviews when appropriate.
• Assigns initial DRG & GMLOS after initial medical necessity review and documents in EMR.
• Completes discharge reviews and escalates concerns as appropriate.
• Identifies and escalates Medicare IP stays requiring attention.
• Collaborates with CM, physicians, payors and other stakeholders regarding medical necessity, status orders, and pre-authorizations/reauthorizations as needed.
• Communicates with departments (Patient Access, PFS, HIM) as appropriate.
• Acts to ensure timely protection of patient care and supports regulatory forms delivery and ongoing authorization processes.
• Assists with patient discharge appeals and in identifying avoidable days; contributes to process improvement initiatives.
• Maintains documentation requirements and supports organizational goals, including VIP/Lean initiatives.

Education

• Required: Graduate of an accredited school of nursing.
• Preferred: Bachelor’s degree in Nursing or Health Care related field

Licensure/Certification/Registration

• Required: Current Oregon RN license
• Preferred: Accredited Case Manager Certification (ACMA: ACM-RN), CCM, CMGT-BC

Experience

• Required: Three (3) years acute care clinical nursing experience
• Preferred: Five (5) years clinical experience in an acute care facility
• Two (2) years Utilization Management experience, or equivalent professional experience
• Two (2) years’ experience in electronic health records

Additional Position Information

• Skills: Advanced critical thinking and conflict resolution; knowledge of regulatory standards (Medicare, Joint Commission); status determination criteria (InterQual/MCG); ability to apply methods with interrater reliability; experience with rapid-cycle process improvement
• General: Ability to interact with all levels within SCHS and external stakeholders; strong teamwork and collaboration; ability to multi-task; attention to detail; strong organizational, written and verbal communication; customer service

Physical and Other Requirements

• Personal Protective Equipment: Must wear PPE as required
• Physical Requirements: Describes hour-by-hour activity levels (standing, sitting, lifting, etc.) and exposure factors
• BBP Exposure: No BBP exposure
• Schedule: Weekly hours: 0; Caregiver Type: Relief; Shift: First Shift; Is Exempt Position? No; Job Family: NON CONTRACT RN SPECIALIST; Schedule: As Scheduled (may include weekends/holidays); Shift Start & End Time: 8:00-16:30