RN Utilization Review

St. Charles Health System; Bend (OR); On-site; USD 100,464 - 150,696; Full time

Job summary

St. Charles Health System is seeking an RN for Utilization Management to perform pre-admission status reviews, ensure medical necessity, and coordinate with CM, physicians, and payors. The role emphasizes data tracking, denial avoidance, and continuous improvement within regulatory requirements.

The position reports to the Manager of Utilization Management and requires strong collaboration across departments to optimize patient status, outcomes, and payer communications.

Qualifications

• Graduate of an accredited nursing school.
• Current Oregon RN license.
• Three years acute care clinical nursing experience.
• Two years Utilization Management experience.
• Two years’ experience working with electronic health records (EHR).

Responsibilities

• Performs pre-admission status recommendation review for multiple care settings and provides status guidance to providers.
• Ensures appropriate patient status upon admission and manages status conversions.
• Ensures completion of admission medical necessity reviews within 24 hours of admission.
• Performs concurrent inpatient medical necessity reviews at least every 3 days and Observation reviews at least every 12 hours.
• Completes discharge reviews and escalates concerns to ensure medical necessity and appropriate authorization.
• Collaborates with Care Management, physicians, payors and other stakeholders to address medical necessity and LOC changes.

Skills

Acute care nursing

UM experience

EHR experience

Education

Graduate of an accredited school of nursing

Job description

Relief, Variable

Pay range: $48.30 - $72.45

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.

POSITION OVERVIEW The Utilization Management Registered Nurse (RN) has well-developed knowledge and skills in areas of utilization management, medical necessity and patient status determination. The UM RN supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. The UM RN is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated and reported. When screening criteria does not align with the physician order or a status conflict is indicated, the UM RN is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. The UM RN is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes. Additionally, the UM RN monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences and designing and implementing process improvement projects 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, may be responsible for providing cross coverage for roles and responsibilities of other UM team members to back-fill during earned time off and/or during backlogs due to peak volumes.
• Performs pre-admission status recommendation review for multiple care settings as assigned (i.e. Emergency Department, Direct Admission/Transfer, and/or elective procedure), to communicate with providers status guidance based on available information.
• Ensures appropriate patient status upon admission and manages patient status conversions, as appropriate.
• Ensures completion of admission medical necessity reviews within 24 hours of admission.
• Completes concurrent inpatient medical necessity reviews at a minimum of every three (3) days unless otherwise specified by payor.
• Completes Observation medical necessity reviews at a minimum of every 12 hours (twice daily).
• Completes Medicare extended stay reviews, as appropriate.
• Assigns an initial working DRG & GMLOS upon completion of initial medical necessity review for IP admission and enters in EMR.
• Completes discharge reviews and ensures completeness of all prior medical necessity reviews and authorizations; escalates concerns, as appropriate.
• Identifies and escalates all 1MN and 2MN Medicare IP stays.
• Collaborates with Care Management (CM) team, as appropriate (i.e. extended observation stays, patients no longer meeting medical necessity, status changes).
• Collaborates with physicians, as appropriate (i.e. to address issues concerning medical necessity, status orders, appropriate level of care, peer-to-peer involvement, etc.).
• Collaborates with payors, as appropriate (i.e. discuss status, changes in LOC, changes in pre-authorizations warranting reauthorization, etc.).
• Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM), as appropriate.
• Escalates Medical Necessity (patient status / LOC) concerns and other UM concerns to Physician Advisor or designated leader, as appropriate.
• Assists with discharge appeal process, as appropriate.
• Provides timely and continual coverage of assigned work area in order to ensure all accounts are complete.
• Assists in the identification of Avoidable Days and communicates information with CM, as appropriate.
• Complies with all documentation requirements.
• Follows up on action items prior to the end of shift.
• Maintains a working knowledge of payor contracts and regulatory requirements and UM specific changes (i.e. changes in authorizations, payor contracts, CMS, regulatory requirements).
• Completes all tasks within department guidelines.
• Adheres to the policies, procedures, rules, regulations and laws of the hospital and federal and state governing bodies.
• Provides support regarding Medicare documentation requirements.
• Obtains verbal admission orders from physicians and monitors for authorization by the physician.
• Participates in the delivery of regulatory forms to patients when appropriate.
• Communicates with insurance companies regarding the medical necessity of the admission and provides clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays.
• Actively participates in clinical performance improvement activities.
• Assists in the collection and reporting of resource and financial indicators including LOS, cost per case, avoidable days, resource utilization, readmission rates, concurrent denials, and appeals.
• Supports the vision, mission and values of the organization in all respects.
• Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
• Provides and maintains a safe environment for caregivers, patients and guests.
• Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
• Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.
• May perform additional duties of similar complexity within the organization, as required or assigned.

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). Commission for Case Manger Certification (CCMC:CCM), Case Management Nurse-Board Certified (CMGT-BC:ANCC).

Experience

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