Utilization Manager (RN)

UNC Health; Hendersonville (NC); On-site; USD 70,000 - 90,000; Full time

Job summary

A healthcare organization in North Carolina seeks a Utilization Manager to evaluate admissions and ensure proper care coordination. This role involves working closely with healthcare teams to conduct utilization reviews, manage patient care transitions, and provide documentation support. Ideal candidates are Registered Nurses with two years of experience and strong communication skills. Full-time position with onsite responsibilities and BLS certification required.

Qualifications

• Must be licensed to practice as a Registered Nurse in North Carolina.
• Two years of experience working as a Registered Nurse.
• Basic Life Support (BLS) certification required.

Responsibilities

• Conducts admission reviews to ensure appropriateness of patient care settings.
• Performs utilization management assessments on assigned patients for optimal outcomes.
• Monitors and guides interdisciplinary documentation for coding accuracy.
• Collaborates to problem-solve issues with complex patients.

Skills

Strong verbal and written communication

Collaboration with interdisciplinary teams

Education

Bachelor's of Science in Nursing (BSN)

Job description

Description

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well‑being of the unique communities we serve.

Summary

The Utilization Manager (UM) assesses new admissions, continued stay and discharge review cases for medical necessity, appropriate class and level of care (LOC). This position works collaboratively with an interdisciplinary team (including physicians, other care providers, payers, etc.) to ensure the patient’s needs are met and care delivery is coordinated. The UM completes Utilization Reviews in accordance with federal regulations and the health system’s Utilization Review Plan.

Responsibilities

• Uses approved criteria and conducts admission review/class change review triggered by patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation services as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Care Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the appropriate staff/payers to assure third‑party payer pre‑certification and/or re‑certifications when required. Discharge Facilitation: Utilizes high‑risk screening criteria to make appropriate referrals. Identifies patient/families with the complex psychosocial, ongoing medical transition planning issues, continuing care needs by initiating appropriate care‑management referrals. Initiates appropriate social work referrals.
• Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts initial and continued stay reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality‑driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels.
• Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation services issues through collaboration with patient/patient representative, multidisciplinary team, third‑party payers and care managers/social workers. Provides information regarding denials and approvals to appropriate staff and/or designated entities. Documents and delivers notifications to patients, patient representative and/or appropriate staff. Reviews Pre‑Scheduled surgery admissions for proper status order for inpatient‑only procedures.
• Collaborates to problem‑solve issues with complex patients and identify trends. Formulates potential solutions with Care Manager and Social Worker and continuously monitors cases/follows up on all action items. Proactively identifies high‑risk cases that need to be escalated to the list that are not scheduled for discussion that week.

Required

• Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states.
• Two (2) years of experience working as a Registered Nurse.
• Strong verbal and written communication.
• Basic Life Support (BLS) certification.

Preferred

• Bachelor's of Science in Nursing (BSN)
• Certification in Case Management

01.6015.1542

Job Details

Legal Employer: Pardee - HCHC

Entity: Pardee UNC Health Care

Organization Unit: Acute Care Case Management

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: PARDEEHOSP

Exempt From Overtime: Exempt: No

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.