Utilization Management Nurse (RN)

Saint Francis Hospital, Inc.; Oklahoma; Hybrid; USD 65,000 - 80,000; Full time

Job summary

Saint Francis Hospital, Inc. seeks a qualified RN to support Utilization Review Management. You will review patient placement across care levels, assist in discharge planning, and work with the care team on authorization and benefits eligibility.

The role requires an active Oklahoma RN license and a minimum of two years in acute care, with strong communication and data synthesis skills to drive quality outcomes and process improvements.

Qualifications

• RN license valid in multi-state or Oklahoma.
• Minimum 2 years of acute care experience.
• Strong organizational, communication, and data interpretation skills.

Responsibilities

• Gathers and prepares clinical information to obtain authorization within review timelines.
• Participates in treatment teams to provide eligibility and level-of-care criteria.
• Assists in discharge planning as needed.
• Identifies QA triggers and reports to UR leadership.
• Reviews eligibility and benefits to validate level of care utilization.
• Investigates and prepares insurance appeals when denial relates to medical necessity.
• Participates in UR process improvement and staff education.

Skills

Organization

Communication

Data analysis

Detail orientation

Clinical data synthesis

MS Office

Education

Nursing degree/licensure

Job description

Job Summary:

Provides administrative and clinical support to the hospital and treatment teams throughout the review of patients including, but not limited to their placement in various levels of care and receipt of necessary services.

Minimum Education:

Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom or Master's degree in Nursing.

Licensure, Registration and/or Certification:

Valid multi-state or State of Oklahoma Registered Nurse License.

Work Experience:

Minimum 2 years of related experience in an acute care setting.

Knowledge, Skills and Abilities:

Ability to organize and prioritize work in an effective and efficient manner. Effective interpersonal, written, and oral communication skills. Demonstrated ability to integrate the analysis of data to discover facts or develop knowledge, concepts, or interpretations. Ability to be detail oriented as required in the examination of numerical data. Ability to synthesize clinical case data into concise summaries. Working knowledge of Microsoft Word, Excel and Access in the preparation of correspondence and reports.

Essential Functions and Responsibilities:

• Gathers, prepares and supplies required clinical/treatment information needed to obtain authorization within the review interval(s) time requirements.
• Participates in treatment team and/or Patient Care Committee by providing information about eligibility, benefits, and criteria for the selected level of care.
• Assists in discharge planning, as needed.
• Identifies QI Triggers for individual patient situations, reporting them promptly to the UM Manager, appropriate clinicians and Process Improvement/Quality Director.
• Reviews eligibility and benefits of patients to validate accurate level of care utilization.
• Investigates and prepares appeals for insurance companies when denial of reimbursement is related to medical necessity or to other treatment issues.
• Participates in quality-of-care and UM process improvement on an ongoing basis and assists with development of the UR Staff Committee's process improvement goals.
• Provides staff education to further the goals of UR.

Decision Making:

The carrying out of non-routine procedures under constantly changing conditions, in conformance with general instructions from supervisor.

Working Relationship:

Works directly with patients and/or customers. Works with internal customers via telephone or face to face interaction. Works with other healthcare professionals and staff. Works frequently with individuals at Director level or above.

Special Job Dimensions:

None.

Supplemental Information:

This document generally describes the essential functions of the job and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.

Utilization Review Management - Yale Campus Location:

Virtual Office, Oklahoma 73105

EOE Protected Veterans/Disability

Saint Francis is a Catholic, not-for-profit Health system based in Tulsa, Oklahoma. We are the largest private employer in Eastern Oklahoma with over 12,000 employees, including 1,000 physicians. The health system is anchored by the 1,112-bed Saint Francis Hospital, the largest hospital in Oklahoma and the 11th largest in the nation. Our system also includes hospitals in south Tulsa, Muskogee and Vinita, as well as 110 Warren Clinic locations from Monkey Island to McAlester, northeastern Oklahoma's only children's hospital, a level IV neonatal intensive care unit, a 168-bed heart hospital, and Tulsa's leading trauma and emergency center.