Utilization Review - Registered Nurse (Weekend)

Mosaic Life Care; Saint Joseph (MO); On-site; USD 70,000 - 95,000; Full time

Job summary

Mosaic Life Care in Missouri is seeking an experienced Utilization Review RN to evaluate inpatient and outpatient services for medical necessity, in collaboration with UM Specialists and Physician Advisors. The role focuses on reviewing admissions, discharges, denials, and appeals while ensuring compliant documentation and effective care transitions.

The ideal candidate holds an RN license in Missouri, with a BSN preferred, at least 3 years of clinical or managed care experience, and strong

Qualifications

• RN licensure in Missouri (or eligible)
• BSN preferred
• 3 years clinical or managed care experience
• Knowledge of medical necessity guidelines (CMS) preferred)
• Strong communication and teamwork skills

Responsibilities

• Conduct inpatient admission, concurrent, and retrospective reviews for Medicare/Medicaid and managed care patients
• Use CMS guidelines to determine appropriate level of care and communicate decisions to care team
• Stay current on regulatory changes affecting delivery or reimbursement
• Identify barriers to patient flow and communicate denials/appeals to team
• Collaborate with physicians and APRNs to ensure appropriate resource utilization and transitions of care
• Represent utilization management on committees and with external groups

Skills

Interdisciplinary collaboration

Communication skills

Education

Bachelor's degree (RN)

BSN - Preferred

Job description

Job Description

The Utilization Review RN will perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Collaborates with UM Specialists, Physician Advisor, and various departments regarding medical necessity of hospital stays from admission authorizations to discharge, including denials and appeals. Strong communication skills are necessary to access available resources and communicate with providers and other members of the interdisciplinary team. Active participation in program development and process improvement efforts is an expectation.

Job Description

The Utilization Review RN will perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Collaborates with UM Specialists, Physician Advisor, and various departments regarding medical necessity of hospital stays from admission authorizations to discharge, including denials and appeals. Strong communication skills are necessary to access available resources and communicate with providers and other members of the interdisciplinary team. Active participation in program development and process improvement efforts is an expectation.

Responsibilities

• Conducts inpatient admission, concurrent, and retrospective review for Medicare and Medicaid beneficiaries as well as managed care and self-pay patients based on CMS guidelines.
• Uses national medical necessity tool to screen for appropriateness for inpatient level of care or observation services based on physician certification including history and physical, treatment plan, potential risks, and basis for expectation of a 2-midnight stay.
• Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services.
• Consistently identifies and records information on any progression-of-care/patient flow barrier and communicates with care team as necessary to notify of denial of continued stay so team can impact barriers.
• Collaborates with physicians and APRNs to influence appropriate utilization of resources, accurate status determination, and transitions of care. Educates members of the patient’s care team on the appropriate access to and use of various levels of care.
• Represents utilization management at various committees, professional organizations, and physician groups as needed.
• Promotes medical documentation that accurately reflects findings and interventions, presence of complications or comorbidities, quality and safety indicators, and patient’s need for continuing stay.
• Confers with attending physician and Physician Advisor if medically unnecessary inpatient treatment is contemplated. Coordinates appeals to denials as necessary.
• Serves as a resource person to physicians, nurses, billing office and other external departments for coverage and compliance issues.
• Other duties as assigned

Education

• Bachelor's Degree - Graduate from school of nursing. - Required
• Bachelor's Degree - BSN - Preferred

Work Experience

• 3 Years - Clinical or managed care experience - Required
• Knowledge of medical necessity guidelines - Preferred

Licenses and Certifications

• Registered Nurse (RN) - State Licensure/Or Compact State Licensure - Licensed in state of Missouri - Required Upon Hire

Travel Requirements

• Must be able to travel between various system facilities and off-site locations as needed. - Required

Essential Technical/Motor Skills

• Hand/eye coordination; speaks clearly; good hearing; computer skills/telephone skills and voice recorder skills.
• Ability to read, write, and speak clearly.

Interpersonal Skills

• Must be able to teach, provide accurate and concise information, answer questions, demonstrate excellent leadership skills, maintain positive relationships with multiple customers, motivate and persuade others.

Essential Physical Requirements

• Physical requirements include standing, walking, and fine motor skills; reaching for items; bend, squat, sit, and climb stairs.
• Sufficient strength and mobility to sit for long periods of time (depending on assignment).

Essential Mental Abilities

• Critical thinking skills, problem-solving skills, negotiating abilities.
• Capable of determining appropriate response to emergency situations.
• Ability to focus and concentrate in order to correctly perform tasks despite numerous distractions and interruptions.
• Ability to maintain professional demeanor to communicate and interact with patients, customers and team members.

Essential Sensory Requirements

• Appropriate functional vision, hearing acuity.

Exposure to Hazards

• Eye and neck strain.

ABOUT US

Mosaic Life Care is a health care system in northwest Missouri. With a vision of transforming community health by being a life-care innovator, Mosaic places the holistic needs of patients first by providing the right care at the right time and place, offering high value and quality health care. Mosaic has a wide array of benefits to meet each employee’s individual needs. Our benefits were designed by listening to people just like you. Mosaic also offers several perks with a focus on ensuring our employees feel valued, including concierge services, employee lounge, wellness programs, free covered parking, free on-site and virtual health clinics and many more. When paired with compensation and recognition, it is what continues to make us the employer of choice for employees at any stage of their journey.