Overview:
The RN Utilization Management Specialist, under the direction of the Manager of Utilization Management, serves a key role in coordinating the organization’s interdisciplinary effort to assess and promote appropriate utilization of health care
resources, provision of high-quality health care, optimal clinical outcomes, and patient and provider satisfaction. The RN UM Specialist will work to track and minimize the inappropriate use of such resources. The RN UM Specialist provides the
Utilization Management function for patients admitted to UPH and facilitates effective utilization of resources through ongoing interactions with physicians, third party payers and regulatory agencies.
This position is open to remote/work from home with strong preference for candidates residing within the UPH geographies of Iowa, Illinois, & Wisconsin. This is a 0.9 FTE Evening shift opening.
Why UnityPoint Health?
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Commitment to our Team – We’ve been named a Top 150 Place to Work in Healthcare 2022 by Becker’s Healthcare for our commitment to our team members.
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Culture – At UnityPoint Health, you matter. Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
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Benefits – Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in.
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Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
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Development – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience.
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Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve.
Visit us at UnityPoint.org/careers to hear more from our team members about why UnityPoint Health is a great place to work. https://dayinthelife.unitypoint.org/
Responsibilities:
Key Accountability
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Performs utilization management reviews using established criteria to confirm medical necessity,
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appropriate level of care and efficient use of resources.
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Maximizes positive financial outcomes for patients and hospital by conducting timely initial
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and ongoing concurrent chart review for hospitalized patients to monitor appropriateness of
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treatment, resource utilization, quality of care.
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Applies utilization criteria using designated software to complete documentation related to
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utilization review activities in an accurate and timely manner for the purpose of providing
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information for other members of the healthcare team and to facilitate decision making.
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Requests secondary reviews with physician advisors as appropriate, if admission or
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continued stay criteria are not met, assuring appropriate and timely level of care status.
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Assesses patient status, including reviewing outpatient surgical and observation
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admissions for the appropriate level of care, and continuously monitors length of stay for
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appropriate and timely medical management.
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Applies accepted potentially avoidable day logic to reviews for accurate and timely data
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collection.
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Proactively monitors insurance approval status in partnership with the UM Administrative
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Coordinator.
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Provides education to staff and physicians regarding medical necessity, levels of care and
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appropriate utilization of resources as needed.
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Pursues denials at the affiliate level in a timely manner to secure payment of services.
Key Accountability
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Serves as a resource to internal and external staff, providers, payers, and patients on issues
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related to utilization management 15%
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Maintains current knowledge of Utilization Review Methodology, software, criteria, and regulations governing various payment systems. o Maintains current knowledge of the UPH Utilization Management Plan.
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Maintains current knowledge of CMS rules (e.g., Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement.
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Coordinates and monitors appeals with internal and external physician advisors for Second Level Review as needed.
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Provides education to patients and families regarding the role of the Utilization Management Specialist and provides clarification when needed on level of care and their payer source regulatory requirements – as needed.
Qualifications:
Education:
- Associates Degree or Diploma (RN) in Nursing · Bachelor’s Degree or higher preferred in nursing, business, or related field
Experience:
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2 years of nursing experience · 5+ years of nursing experience · Experience in Utilization Management, case management, denials, or managed care highly preferred
License(s)/Certification(s):
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Registered Nurse – Licensed and registered in the appropriate state(s)
- Valid driver’s license when driving any vehicle for work-related reasons
Knowledge/Skills/Abilities:
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Professional communication – written & verbal
- Microsoft Office proficiency (Outlook, Word, Excel)
- Customer/patient focused
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Self-motivated
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Ability to work with minimal supervision
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Ability to manage priorities/deadlines
- Ability to multi-task and prioritize workload · Flexible and adaptable to changing environment
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Excellent critical thinking and problem-solving skills · Positive attitude with team-oriented approach
- Ability to give work direction to non-clinical staff