RN Utilization Mgt Specialist II - Cincinnati, United States - cchmc

Description

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RN Utilization Management Specialist (Remote)Holiday and Saturday check-ins will be required in order to maintain compliancy

Expected Starting Salary Range:

Utilization Management program is to assure that all members receive all medically necessary services at the appropriate level and setting of care in a timely, efficient manner.

The Medical Management Program evaluates the appropriateness of care, over and underutilization of both inpatient and outpatient services, and provides ongoing performance feedback to the Managed Care Plan derived from prospective, concurrent, and retrospective review of clinical information.

Scope:
Responsible for required correspondence.

Using professional education independently documents; identifies and communicates with Health Partners; Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care in a timely and cost-effective manner.

REPRESENTATIVE RESPONSIBILITIESUtilization ManagementUtilization Management:

Independently working more complex prospective, retrospective and concurrent review and processing of authorization requests for inpatient admissions, outpatient procedures, homecare services and durable medical equipment.

Generates required correspondence, including denial letters, based on medical necessity and administrative review process while maintaining productivity and turnaround time.

QualityWork with management team to ensure 100% correct letter and less than 2% error rate are met. Uses independent judgement to ensure templates are compliant with Federal, State and Regulatory requirements. Identify and refer appropriate members for care management and quality issues to Quality Improvement. Recommends process improvements and provides documentation for processes to the department.

Discharge PlanningDocument, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care in a timely and cost-effective manner.

Interfaces with physician reviewers to optimize the written communication to members and referring providers. ComplianceMeet third-party payer standards and requirements. Maintains knowledge of changes as impacts regulatory/accrediting compliance for reimbursement.

Assist Director in the reporting of information as set forth in the PI plan, i.e., appropriateness of admissions and continued stay reviews including when known, the over and underutilization of resources.

Participate in interdepartmental meetings to promote knowledge, troubleshoot, problem shoot and resolve issues as relates to utilization management.

Serves as an educational and communications resource to Administration, Department heads, physicians and other necessary groups regarding the utilization management activity and process.

Keep the department manager informed of problems, as necessary. LeadershipProvide guidance to and assist with oversight of non-clinical staff, including training and education of Specialist I. Act as a primary point of contact for the Utilization Management team. Answers questions and provide guidance for difficult reviews and processes.


Qualifications:

EDUCATION/EXPERIENCERequired:
Bachelor of Science in Nursing 3 years of work experience in a related job discipline. Current, unrestricted Registered Nurse (RN)Preferred:

Utilization Management ExperienceManaged Care ExperiencePediatric ExperienceUnique Skills:

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