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RN Utilization Mgt Specialist - Care Management

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Job ID: 15218
Location: Bellingham, WA
Work Type: Part Time
Shift: Day
Shift Length: 8 Hours
FTE: 0.80
Benefit Eligibility: Full-time benefits

Job Description

Description

PeaceHealth is seeking a RN Utilization Mgt Specialist - Care Management for a Part Time, 0.80 FTE, Day position.  Hourly compensation starts at $35.48, more depending on experience.

Shift start times may be variable 0800-1630, 0830-1700 or 0900-1730.

Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.

JOB SUMMARY

The RN Utilization Management Specialist promotes efficient utilization of resources and appropriate reimbursement of care and services through clinical review of cases and collaboration with the health care team, external payers and internal departments. Provides solutions and recommendations based on analysis of utilization management processes and outcomes. Acts as a liaison between the hospital, external agencies and third party payers to exchange information necessary to achieve timely outcomes. Facilitates authorization and reimbursement issues through a thorough review of the clinical information, clarification from providers and internal departments such as Patient Financial Services, Health Information Management, Admitting, Registration and Clinical Documentation Integrity as needed.

ESSENTIAL FUNCTIONS

  1. Oversees work queues in the electronic medical record to assure that a patient’s admission class is supported by the severity of illness and intensity of services delivered for inpatient, ambulatory, obstetrics, and observation stays.
  2. Assures payer authorization for reimbursement is obtained on urgent and emergent hospital admissions, and that authorization continues through the episode of care based on ongoing medical necessity as supported by application of acute care criteria.
  3. Oversees perioperative pre-authorization and patient class order reconciliation process.
  4. Facilitates and monitors adherence to the Medicare 2 midnight rule and the Medicare Inpatient-only procedure list.
  5. Coordinates contact between providers and payers by facilitating peer-to-peer denial appeals.
  6. Engages the physician advisor in making patient class determinations, as required.
  7. Prepares, issues, oversees, and tracks the distribution of notices of non-coverage.
  8. Completes utilization review of episodes of care post-discharge, identifying charges that should not be billed due to incorrect patient class.
  9. Analyzes one-day Medicare inpatient stays and identifies and reports provider training needs. Works collaboratively with Patient Accounting, Patient Admission and Registration, HIM, and the Finance Department to optimize reimbursement.
  10. Manages and responds to concurrent and post-discharge third party payer denials of outpatient and inpatient cases alleged to be medically inappropriate.
  11. Internal expert for RN Case Management staff and others on documentation and reimbursement requirements. Serves as a resource to the health care team for utilization and denial management. Liaises with provider office staff and facilitates meetings with payers.
  12. Maintains databases regarding payer requirements, payer reviews, contacts, decisions and appeals, and reports trends relative to third party payer reviews.
  13. Assists with governmental agency requests for information and prepares / provides reports. Works to decrease avoidable days and contributes to organization success targets.
  14. Participates on the Utilization Review Committee.
  15. Performs other duties as assigned.

QUALIFICATIONS: Required unless otherwise stated

EDUCATION:

  • Graduate of an accredited school of nursing.
  • Bachelors’ degree strongly preferred.
  • Masters’ degree preferred.

EXPERIENCE/TRAINING:

  • Minimum of five years’ experience in an acute care hospital required.
  • Minimum of three years’ successful performance in utilization management required.
  • Third-party reimbursement knowledge required.
  • Experience in surgery, emergency and/or critical care preferred.
  • Strong statistical, data analysis, and clinical application experience preferred.
  • Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity preferred.

LICENSE/CERTIFICATION:

  • Current Registered Nurse licensure in the state in which nurse will be practicing.
  • Current BLS (Basic Life Support) certification may be required within a standard grace from hire or transfer period, as specified in the PeaceHealth Policy Resuscitation Training Completion Requirements, or upon hire.
  • Specialty Certification preferred.

KNOWLEDGE/SKILLS/ABILITIES:

  • Demonstrated competence in denial/appeals management and utilization management.
  • Strong organizational and analytic skills.
  • Highly effective written and verbal communication skills.
  • Proficient with database management, spreadsheets and word processing.
  • Current knowledge of regulatory and accreditation requirements related to data review, quality measures, performance improvement and measurement systems.

ST. JOSEPH PHYSICAL/COGNITIVE REQUIREMENTS:

  • Work requires active physical exertion up to 66% of the time.
  • Ability to lift, push, pull objects weighing 25 lbs. or less.
  • Work may require frequent exposure to conditions involving minor cold, heat, poor ventilation, or sharp instruments such as syringes or lancets. 
  • Reasonably anticipated exposure to blood and body fluids once per month or more.
  • Job duties require intense concentration and attention to detail up to 34-65% of work time.

This position is represented by a collective bargaining agreement. There may be more than one opening on this posting.

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.  

For full consideration of your skills and abilities, please attach a current resume with your application.  EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.

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