Utilization Management Spec RN
Overview:
Fairview Health Services is hiring a casual Utilization Management Spec RN to join our Revenue Cycle Management team. This is a remote position.
Two shifts a month would be considered casual for this position.
This position, under Revenue Cycle Management, is responsible for the completion of admission and continued stay clinical review, including obtaining insurance certification/authorization necessary to secure reimbursement. This position assesses the patients plan of care and progress of the patient throughout an acute care and/or outpatient episode (observation) across the M Health Fairview system.
Responsibilities/Job Description:
Job Expectations:
Perform and document timely and accurate utilization management review to ensure compliance with all policies, procedures, regulatory and accreditation requirements.
Adhere to applicable professional standards using nationally recognized evidence-based clinical criteria and M Health Fairview guidelines to determine the appropriateness of level of care, length of stay and discharge planning.
Facilitate secondary physician review with the physician advisor and/or attending physician on required cases to ensure accurate level of care assignment and reimbursement.
Manage resolution of concurrent payer denials through submission and coordination of appeals related to medical necessity (level of care) and tracks all work related to denials/appeals.
Educate internal members of the health care team on utilization management workflow and managed care concepts.
Work on a variety of special projects and assume other duties as assigned by the Utilization Review Manager or Supervisor.
Understand and focus on key performance indicators.
Contribute to the process or enablement of collecting expected reimbursement.
Understand and adhere to Revenue Cycles Escalation Policy.
Organization Expectations, as applicable:
Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served.
* Partners with patient care giver in care/decision making.
Communicates in a respective manner.
Ensures a safe, secure environment.
Individualizes plan of care to meet patient needs.
Modifies clinical interventions based on population served.
Provides patient education based on as assessment of learning needs of patient/care giver.
Fulfills all organizational requirements.
Completes all required learning relevant to the role.
Complies with and maintains knowledge of all relevant laws, regulations, policies, procedures, and standards.
Fosters a culture of improvement, efficiency, and innovative thinking.
Performs other duties as assigned.
Qualifications:
Required
Bachelors degree in Nursing
3-5 years Utilization Review or Case Management experience in hospital, clinic, insurance company, or long-term care facility.
Minimum of 1-3 years of acute care hospital nursing experience.
Current RN License
Preferred
Minimum of 1-year Epic experience.
Minimum 1-year experience using medical necessity screening criteria, such as InterQual or MCG.
Minimum of 3-5 years of acute care hospital nursing experience.
Excellent computer and database management skills.
Apply Now
Fairview Health Services is hiring a casual Utilization Management Spec RN to join our Revenue Cycle Management team. This is a remote position.
Two shifts a month would be considered casual for this position.
This position, under Revenue Cycle Management, is responsible for the completion of admission and continued stay clinical review, including obtaining insurance certification/authorization necessary to secure reimbursement. This position assesses the patients plan of care and progress of the patient throughout an acute care and/or outpatient episode (observation) across the M Health Fairview system.
Responsibilities/Job Description:
Job Expectations:
Perform and document timely and accurate utilization management review to ensure compliance with all policies, procedures, regulatory and accreditation requirements.
Adhere to applicable professional standards using nationally recognized evidence-based clinical criteria and M Health Fairview guidelines to determine the appropriateness of level of care, length of stay and discharge planning.
Facilitate secondary physician review with the physician advisor and/or attending physician on required cases to ensure accurate level of care assignment and reimbursement.
Manage resolution of concurrent payer denials through submission and coordination of appeals related to medical necessity (level of care) and tracks all work related to denials/appeals.
Educate internal members of the health care team on utilization management workflow and managed care concepts.
Work on a variety of special projects and assume other duties as assigned by the Utilization Review Manager or Supervisor.
Understand and focus on key performance indicators.
Contribute to the process or enablement of collecting expected reimbursement.
Understand and adhere to Revenue Cycles Escalation Policy.
Organization Expectations, as applicable:
Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served.
* Partners with patient care giver in care/decision making.
Communicates in a respective manner.
Ensures a safe, secure environment.
Individualizes plan of care to meet patient needs.
Modifies clinical interventions based on population served.
Provides patient education based on as assessment of learning needs of patient/care giver.
Fulfills all organizational requirements.
Completes all required learning relevant to the role.
Complies with and maintains knowledge of all relevant laws, regulations, policies, procedures, and standards.
Fosters a culture of improvement, efficiency, and innovative thinking.
Performs other duties as assigned.
Qualifications:
Required
Bachelors degree in Nursing
3-5 years Utilization Review or Case Management experience in hospital, clinic, insurance company, or long-term care facility.
Minimum of 1-3 years of acute care hospital nursing experience.
Current RN License
Preferred
Minimum of 1-year Epic experience.
Minimum 1-year experience using medical necessity screening criteria, such as InterQual or MCG.
Minimum of 3-5 years of acute care hospital nursing experience.
Excellent computer and database management skills.
Apply Now