RN - Utilization Management Specialist

10000 Sanford; United States; Hybrid; USD 39,000 - 53,000; Full time

Job summary

Sanford Health is seeking a Registered Nurse to perform level of care medical necessity reviews and utilization management within patient records. The role includes coordinating authorizations, pre-admission reviews and DRG-related coding, while ensuring adherence to CMS, NCD/LCD, and payer standards.

You will collaborate with physicians and interdepartmental teams to improve documentation and resource utilization.

Qualifications

• Bachelor's degree in nursing required or preferred.
• Graduate from a nationally accredited nursing program (CCNE/ACEN/NLN CNEA).
• Currently holds an unencumbered RN license in the state.
• Maintains required competencies and certifications for the department.

Responsibilities

• Conduct level of care medical necessity reviews in patient records.
• Perform utilization management activities to ensure compliance with standards.
• Coordinate authorization, pre-admission reviews and DRG-related coding.
• Collaborate with physicians and healthcare team to improve documentation and efficiency.
• Monitor payer standards and assist with audits and reports.
• Provide guidance and training to team members as needed.

Skills

RN license

UM experience

InterQual knowledge

Education

Bachelor's degree in nursing

CCNE/ACEN/NLN CNEA accredited program

Tools

InterQual criteria

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.

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.

If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-949-5678 or send an email to [e-mail].

The Sanford organization owns and manages multiple distinct brands, including Sanford Health, Marshfield Clinic, and Good Samaritan, as well as Lewis Drug, Sanford Health Equip, Solutions by Sanford, Great Shots, and Blue Rock Bar & Grill. 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. Headquartered in Sioux Falls, South Dakota, the organization has 53,000 employees and serves over 2 million patients and nearly 425,000 health plan members across the upper Midwest including South Dakota, North Dakota, Minnesota, Wyoming, Iowa, Wisconsin and the Upper Peninsula of Michigan. The integrated nonprofit health system includes a network of 56 hospitals, 288 clinic locations, 147 senior care communities, 4,000 physicians and advanced practice providers and nearly 1,500 active clinical trials and studies. The organization’s transformational virtual care initiative brings patients closer to care with access to 78 specialties. Learn more about Sanford Health’s commitment to shaping the future of rural health care across the lifespan at sanfordhealth.org or Sanford Health News.

Good Samaritan, one of the nation’s largest nonprofit providers of senior care and services, is committed to transforming the aging experience through innovation, compassion and personalized care. As part of Sanford Health, an integrated nonprofit health system headquartered in Sioux Falls, South Dakota, Good Samaritan serves 10,000 seniors and offers access to a full continuum of care, including 94 rehabilitation and skilled nursing centers, 56 assisted living and memory care facilities, 44 independent living locations and 37 home health and hospice agencies. The senior care provider delivers services across the upper Midwest, with 70% of residents living in rural communities. Learn more about Good Samaritan’s mission and commitment to delivering high quality senior care in rural America at good-sam.com.