Utilization Management RN

Bryan Health; Lincoln (NE); On-site; USD 70,000 - 100,000; Full time

Job summary

Bryan Health in Lincoln, NE is seeking a Registered Nurse for utilization management. The role focuses on ensuring medical necessity, coordinating with interdisciplinary teams and navigating payer policies to optimize patient care and hospital finances.

Requires NE RN licensure, 2 years clinical experience, and BLS. The position emphasizes collaboration, adherence to guidelines, and ongoing professional development in a hospital setting.

Qualifications

• Maintains clinical competency as required for the unit.
• Knowledge of governmental and third party payer regulations (CMS, CARF, FIM).
• Knowledge of computer hardware and software relevant to work.
• Skilled in conflict diffusion and resolution.
• Effective written and verbal communication.
• Ability to conduct crucial conversations.
• Ability to build strong working relationships with staff and providers.
• Strong problem solving and independent thinking.
• Maintain confidentiality of sensitive information.
• Ability to prioritize tasks with minimal supervision.
• Maintain regular, punctual attendance.

Responsibilities

• Commit to mission, vision and core values.
• Perform utilization review activities (concurrent/retrospective).
• Determine medical necessity using guidelines/criteria.
• Collaborate with providers to manage length of stay and care.
• Refer cases to reviewing physician when criteria not met.
• Participate in denials/appeals process and follow-up.
• Serve as resource on level of care and payer rules.
• Propose cost effective and efficient care plans.
• Maintain understanding of reimbursement methodologies.
• Promote quality improvement and patient outcomes.
• Engage in professional development and attend meetings.
• Perform other related duties as assigned.

Skills

Clinical competency

Payer regulations

Communication skills

Critical thinking

Confidentiality

Relationship building

Problem solving

Time management

Education

RN licensure (Nebraska)

Job description

GENERAL SUMMARY:

Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient's hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient's hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient's and hospitals financial well-being.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Performs utilization review activities, including concurrent and retrospective reviews as required.

3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria.

4. *Collaborates with the patient's provider and other healthcare team members in managing the patient's length of stay and determining the continuing medical necessity of continued stays.

5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm.

6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up.

7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay.

8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care.

9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship.

10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives.

11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

12. Participates in meetings, committees and department projects as assigned.

13. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*". Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient's growth and developmental needs, annual skill competency verification and mandatory education and competencies.

2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM).

3. Knowledge of computer hardware equipment and software applications relevant to work functions.

4. Skill in conflict diffusion and resolution.

5. Ability to communicate effectively both verbally and in writing.

6. Ability to perform crucial conversations with desired outcomes.

7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.

8. Ability to problem solve and engage independent critical thinking skills.

9. Ability to maintain confidentiality relevant to sensitive information.

10. Ability to prioritize work demands and work with minimal supervision.

11. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

Basic Life Support (BLS) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.