Utilization Management RN — Optimize Care & Appeals

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

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