Utilization Management Specialist

Logan Health Medical Center; United States; A distancia; USD 52.000 - 75.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Four day work week

Affordable Medical Benefits package

401(k) with generous immediate match

Fitness Center Membership Discount

Supportive nursing culture

Fully remote opportunity in MT

Descripción de la vacante

Logan Health Medical Center is seeking a Utilization Management Specialist to review admissions across the system and determine appropriate status. This role suits an RN or Social Worker with acute care experience, capable of collaborating with physicians, case management and insurers.

The position is fully remote for Montana residents and offers a four-day work week with competitive benefits. You will evaluate documentation, ensure medical necessity, and support timely care transitions while

Formación

• Current Montana RN license or multi-state compact license with Montana authority.
• Bachelor’s degree in Social Work; Associate’s degree required, Bachelor’s preferred.
• CCM certification preferred.
• Minimum five years’ acute care hospital experience; prior inpatient UM/patient status review preferred.
• Knowledge of Medicare/Medicaid UM regulations and denial management preferred.

Responsabilidades

• Review daily inpatient and observation admissions across the Logan Health system to determine admission status.
• Evaluate physician documentation and patient data for medical necessity.
• Reassess patients to ensure continued criteria for level of care.
• Collaborate with UM Advisor, case management, and insurance to facilitate authorizations.
• Assist with peer-to-peer physician reviews and coordinate scheduling.
• Communicate with providers and staff to ensure accurate documentation and care transitions.
• Identify and address issues delaying reviews or affecting compliance.
• Utilize EMR efficiently for documentation, review, and reporting.
• Work independently while collaborating with the interdisciplinary team.

Conocimientos

Attention to detail

Clinical judgment

Communication skills

Analytical thinking

Independent work

Collaboration

Educación

Bachelor's degree in Social Work

Associate's degree in Social Work

Herramientas

EMR systems

Descripción del empleo

Bring Your Clinical Expertise to Logan Health’s Utilization Management Team!

Our Mission: Quality, compassionate care for all. Our Vision: Reimagine health care through connection, service and innovation. Our Core Values: Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence.

Logan Health is searching for a Utilization Management Specialist to join our dedicated team! Our Utilization Management Specialists play a vital role in reviewing admissions across the Logan Health system to determine appropriate admission status. This position is ideal for an RN or Social Worker with strong acute care (hospital) experience, exceptional communication skills, and the confidence to collaborate with physicians, case management, and insurance partners. You’ll make a direct impact on patient outcomes and resource management while working in a supportive, mission-driven environment.

What we offer you!

• Four day work week!
• Affordable Medical Benefits package
• 401(k) with generous immediate employer match
• Logan Health Fitness Center Membership Discount!
• A supportive, mission-driven nursing culture focused on quality, compassion and person-centered care!
• Fully remote opportunity - Must currently reside in the State of Montana. We are only considering Montana applicants at this time.

Pay Scale: Ranges from $37.50-$54.25 depending on prior related experience and equity considerations.

Position/schedule highlights

• Full-time, four 10-hour shifts per week
• Every fourth weekend (Saturday & Sunday) rotation
• Will participate in rotating holiday rotation coverage
• Variable shifts - Morning shifts typically start around 7 a.m.; afternoon shifts begin around 10 a.m.

Here’s some of what you’ll be doing:

• Review all daily inpatient and observation admissions across the Logan Health system
• Evaluate physician documentation and patient data to determine appropriate admission status
• Reassess patients throughout their stay to ensure continued criteria for level of care are met
• Collaborate with the physician UM Advisor, case management team, and insurance partners to facilitate authorizations and medical necessity reviews
• Assist with scheduling and coordinating peer-to-peer physician reviews
• Communicate with providers, nurses, and other stakeholders to ensure accurate documentation and smooth care transitions
• Identify and address any issues that could delay reviews or affect compliance
• Utilize electronic medical records efficiently to support documentation, review, and reporting
• Work independently while maintaining strong collaboration within the interdisciplinary team

Who you are:

You’re detail-oriented, confident in your clinical judgment, and comfortable managing multiple priorities in a fast-paced environment. You bring experience in acute care and understand how to interpret documentation and regulations accurately. Strong computer literacy, analytical thinking, and professional communication are essential for success in this role.

Don’t miss this rare opportunity to be part of a team making a real impact!

Qualifications

• Minimum of one (1) of the following required: Current Montana RN License or a multi state compact license with authorization to practice nursing within the state of Montana
• Bachelor’s degree in Social Work Associate’s degree required. Bachelor’s degree preferred.
• CCM Certification preferred.
• Minimum of five (5) years’ acute care hospital experience required. Prior experience as an inpatient utilization review nurse or UM specialist preferred.
• Knowledge in areas of: Medicare and Medicaid UM regulations, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management preferred.
• Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
• Excellent verbal and written communication skills including the ability to communicate effectively with various audiences

Other Job Specific Duties

• Coordinates and facilitates correct identification of patient status.
• Utilizes a validated criteria set and ensures hospitalized patients have the correct admission status.
• Completes short stay work queue reviews and tracks and trends results for reporting and education purposes.
• Identifies opportunities for process and system improvement and initiates and leads performance initiatives as indicated.
• Identifies and facilitates resolution of system process issues impeding UM functions.
• Identifies and resolves delays and obstacles as appropriate.
• Collaborates with appropriate stakeholders to answer clinical questions related to medical necessity and patient status.
• Performs concurrent and retrospective reviews as directed by assigned leadership.
• Assists with preparation of appeal letters for insurance denials, audit activities, and responds to payer inquiries in a professional manner.
• Interacts with appropriate stakeholders in a timely, positive manner to resolve UM and patient status issues.
• Seeks consultation from appropriate disciplines and/or departments as required to expedite care and facilitate timely and accurate documentation of patient status and clinical reviews.
• Refers UM issues to assigned leadership and/or appropriate stakeholder(s) in a timely manner and monitors until it is resolved.
• Participates in development, implementation, teaching, evaluation, and revision of departmental standards related to UM.
• Participate in the orientation of new department staff specific to UM.
• Documents UM, quality and risk concerns and refers to appropriate departments as applicable for follow up.

The above essential functions are representative of major duties of positions in this job classification. Specific duties and responsibilities may vary based upon departmental needs. Other duties may be assigned similar to the above consistent with knowledge, skills and abilities required for the job. Not all of the duties may be assigned to a position.

Shift schedule

Variable - 10 Hours (United States of America) Schedule: Schedule: Full-time, 40 hours per week. Schedule is four 10-hour variable rotating shifts. Morning shifts begin typically at 7:00 a.m. and afternoon shifts begin around 10:00 a.m. Weekend shift (Saturday & Sunday) rotation every fourth week is also required. Holiday coverage rotation also required. Logan Health operates 24 hours per day, seven days per week. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.

Notice of Pre-Employment Screening Requirements

If you receive a job offer, please note all offers are contingent upon passing a pre-employment screening, which includes: Criminal background check Reference checks Drug Screening Health and Immunizations Screening Physical Demand Review/Screening.

Equal Opportunity Employer

Logan Health is an Equal Opportunity Employer (EOE/AA/M-F/Vet/Disability). We encourage all qualified individuals to apply for employment. We do not discriminate against any applicant or employee based on protected veteran status, race, color, gender, sexual orientation, religion, national origin, age, disability or any other basis protected by applicable law. If you require accommodation to complete the application, testing or interview process, please notify Human Resources.

Company Mission, Vision, Values

At Logan Health, our work is driven by our mission, vision, and values: Our Mission Quality, compassionate care for all. Our Vision Reimagine health care through connection, service, and innovation. Our Core Values Be Kind – We foster compassion and positivity in our work environment. Work Together – Collaboration leads to innovation, efficiency, and improved communication. Trust and Be Trusted – We build trust by acting with authenticity, empathy, and good intent. Strive for Excellence – We continually push ourselves to improve, innovate, and deliver high-quality care and services.