Utilization Management RN - FT Days

Jefferson Health; Philadelphia, Northern (Philadelphia County, KY); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Thomas Jefferson University Hospitals, Inc. seeks an experienced Registered Nurse with utilization management responsibilities in Philadelphia.

You will apply medical necessity criteria to determine patient status, monitor admissions and stays, and coordinate appeals with payors. Ideal candidates hold a nursing degree and an active RN license in PA (NJ acceptable as applicable) with at least 3 years in case management, discharge planning, or UM, and strong communication skills to work with an

Qualifications

• Bachelor’s Degree in Nursing.
• 3 years case management, discharge planning or utilization management experience.
• Knowledge of managed care, governmental and third party payors reimbursement.
• Proficient with InterQual and mcg criteria.
• Ability to prioritize workload and collaborate with others to meet deadlines.
• Knowledge of regulations affecting healthcare practices.

Responsibilities

• Interacts with co-workers, visitors, and other staff consistent with Jefferson’s values.
• Collaborates with Physician Advisor and Multidisciplinary Team to facilitate Case Management.
• Applies approved utilization acuity criteria to monitor admissions and continued stays and documents findings.
• Performs appeal process in coordination with third party payor protocols and timelines.

Skills

Strong interpersonal relationships

Prioritize workload

Communication skills

Team collaboration

Oral and written communication

Education

Bachelor’s Degree in Nursing

RN license PA

RN license NJ

Tools

InterQual criteria

mcg criteria

Job description

**Job Details**Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Performs denial and appeal activities for inpatient hospital care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.**Job Description** **Summary** Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Performs denial and appeal activities for inpatient hospital care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care. **Job Duties*** Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.* Collaborates with the Physician Advisor and members of the Multidisciplinary Team to facilitate the Case Management Condition 44 process.* Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards.* Performs appeal process in coordination with specific third party payor format, protocols, and timelines. **Minimum Qualifications*** Bachelor’s Degree Nursing* 3 years case management experience, discharge planning or utilization management experience required.* Knowledge of managed care, governmental and third party payors reimbursement.* Must be proficient with InterQual and mcg criteria and its application.* Strong interpersonal relationships.* Ability to: prioritize workload; collaborate with others to meet multiple deadlines; communicate effectively orally and in writing; work in a team environment, document in electronic health records.* Knowledge of the medical, social, economic, and other services provided by other departments or facilities, and the ability to integrate these multidisciplinary treatments for optimal patient care.* Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.* Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.* Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.* Understands the impact of developmental stage on adjustment to illness/trauma.* Demonstrates ability to identify adolescent behaviors concerning body image, independence, sexual identity, interference with ability to establish identity, tendency to deny or minimize severity of illness.* Demonstrates understanding of end of life issues.* Exhibits effective communication skills while working with neonate, infant, adolescent, and geriatric patient.* Demonstrates ability to recognize the signs of physical and/or emotional abuse or neglect to help identify victims.* Demonstrates the ability to identify hearing and sight deficiencies in geriatric population.* RN - Licensed Registered Nurse\\_PA - State of Pennsylvania* RN - Licensed Registered Nurse\\_NJ - State of New Jersey **Additional Qualifications** **Physical Demands** Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, \\*patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR. Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.**Work Shift**Workday Day (United States of America)**Worker Sub Type**Regular**Employee Entity**Thomas Jefferson University Hospitals, Inc.**Primary Location Address**1101 Market, Philadelphia, Pennsylvania, United States of America