RN - Utilization Management Specialist

sanford; Sioux Falls (SD); On-site; USD 81,664,000 - 110,318,000; Full time

Job summary

Sanford Health in Sioux Falls, SD, seeks a registered nurse to conduct level-of-care medical necessity reviews within patient records and perform utilization management activities to ensure accreditation compliance.

Responsibilities include chart reviews, prior authorizations, and DRG-related coding, with collaboration across the care team to optimize patient outcomes and resource use. Training is provided on-site with future remote-work considerations.

Qualifications

• Bachelor's degree in nursing preferred.
• Graduate from a nationally accredited nursing program.
• Currently holds an unencumbered RN license with state board.

Responsibilities

• Perform level-of-care medical necessity reviews within patient records.
• Assist with and manage insurance coverage, denials, and prior authorizations.
• Coordinate UM activities and DRG coding for medical necessity and resource use.
• Collaborate with physicians and clinical staff to improve documentation and outcomes.
• Ensure compliance with CMS, NCD/LCD, and state/federal regulations; participate in audits.

Skills

Interpersonal skills

RN license

Education

Bachelor's degree in nursing

RN license

Job description

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America's heartland.

Work Shift:

8 Hours - Day Shifts (United States of America)

Scheduled Weekly Hours:

40

Compensation:

Salary Range: $28.50 - $38.50

Union Position:

No

Department Details

• Monday-Friday
• 8 hour Days Shifts
• Every 7-8 Weekend Rotation (Saturday only)
• Training on-site with consideration of remote work after 6 months to 1 year

Summary

Conduct level of care medical necessity reviews within patient's medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable. Completes activities relating to determination of medical necessity, authorization, continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments.

Job Description

Workflows may include patient chart review, and assisting with and managing of insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, as well as length of stay. Ensure validation of appropriate level of care for pre-admission surgical reviews prior to admission. Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control. Ability to determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed. May also be actively involved in collaborating with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes when appropriate. Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services. Dynamic and tactful interpersonal skills, particularly in relating to physicians and other health care professionals. Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization. Assists the department in monitoring the utilization of resources, risk management and quality of care for patients in accordance with guidelines and criteria. Assist in report preparation, correspondence, and maintenance of appropriate records. Ensure services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements. Maintain working knowledge of payer standards for UM functions for authorization requirements. May assist with additional special projects related to work, upcoming initiatives, new organizational goals and audits when delegated. Considered a resource to all team members and acts as a point of contact for guidance, training, and assisting with questions. Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs within interdepartmental and clinical units are required.

Qualifications

Bachelor's degree in nursing preferred. Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).

Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing. Obtains and subsequently maintains required department specific competencies and certifications.

Sanford is an EEO/AA Employer M/F/Disability/Vet.