Utilization Review RN: Care Continuum Advocate

Western Missouri Medical Center; Warrensburg (MO); On-site; USD 70,000 - 100,000; Full time

Job summary

Western Missouri Medical Center seeks an RN for Utilization Management to review admissions for appropriateness and manage access points from ED and other departments. Responsibilities include applying InterQual/MCG criteria, coordinating with physicians and care teams, and ensuring compliant documentation and billing practices.

The role emphasizes collaboration with healthcare staff, continuous improvement in utilization management, and adherence to CMS guidelines to optimize patient care

Qualifications

• High school diploma or equivalent.
• Currently licensed to practice as a professional Registered Nurse (RN) in Missouri.
• 3-5 years of recent hospital-based patient care required.
• 3-5 years Milliman or InterQual experience preferred.
• HMO, managed care, PPO, Utilization Management/medical management experience is a plus.
• Strong computer skills, excellent communication skills, team building, and leadership ability.
• Self-motivated and able to work within the established policies, procedures and practices prescribed by the hospital/clinic.

Responsibilities

• Review inpatient and outpatient admissions for appropriateness.
• Evaluate medical necessity and efficient use of care services.
• Apply InterQual and MCG criteria to determine level of care.
• Collaborate with physicians and care teams to certify level of care and coordinate patient movement.
• Communicate with third party payors regarding certification and admission reviews.
• Support quality improvement and documentation accuracy in patient records.

Skills

Strong computer skills

Excellent communication skills

Team building

Leadership ability

Education

High school diploma or equivalent

Tools

InterQual experience

Milliman experience

Job description

Western Missouri Medical Center seeks an RN for Utilization Management to review admissions for appropriateness and manage access points from ED and other departments. Responsibilities include applying InterQual/MCG criteria, coordinating with physicians and care teams, and ensuring compliant documentation and billing practices.

The role emphasizes collaboration with healthcare staff, continuous improvement in utilization management, and adherence to CMS guidelines to optimize patient care