RN Utilization Manager - (Per Diem) Care Management

UNC Health; Smithfield (NC); On-site; USD 49,000 - 71,000; Full time

Job summary

UNC Health in Smithfield, NC seeks a Utilization Manager to collaborate with patients, families, and interdisciplinary teams, guiding care from acute admission to post-discharge with emphasis on quality and efficient utilization. The role supports revenue protection and uses established criteria for reviews.

The position is per diem, onsite, daytime, with a 4-hour weekly schedule. Licensure as a Registered Nurse in North Carolina is required, with a Bachelor’s or Master’s in Nursing preferred

Qualifications

• Registered nurse licensed in North Carolina.
• Bachelor's or Master's degree in Nursing as required within seven years of hire.

Responsibilities

• Conduct admission reviews within 24 hours to ensure appropriate setting.
• Coordinate discharge planning with care teams and social work.
• Perform utilization management assessments and continued stay reviews.
• Communicate with physicians, payors, and interdisciplinary teams to optimize care and reimbursement.

Skills

Clinical Review

Discharge Planning

Utilization Management

Interdisciplinary Collaboration

Education

Licensed RN (NC)

Bachelor's or Master's in Nursing

Tools

EHR/EMR

Job description

Description

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Summary

Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone.

Responsibilities

• Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager.
• Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals.
• Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels.
• Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications.

Other Information

Other information:

Education Requirements

• Graduation from a state-accredited school of professional nursing
• If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date.

Licensure/Certification Requirements

• Licensed to practice as a Registered Nurse in the state of North Carolina.

Professional Experience Requirements

• Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience.

Job Details

Legal Employer: NCHEALTH
Entity: Johnston Health
Organization Unit: Care Management -
Work Type: Per Diem
Standard Hours Per Week: 4.00
Salary Range: $35.87 - $51.57 per hour (Hiring Range)
Pay offers are determined by experience and internal equity
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: US:NC:Smithfield
Exempt From Overtime: Exempt: Yes
This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position.
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email [e-mail] if you need a reasonable accommodation to search and/or to apply for a career opportunity.