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 patient’s 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 Cycle’s 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 • Bachelor’s 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 Job!