Under the supervision Hospital Care Management, incumbent promotes appropriate utilization, high quality care and cost effective outcomes. Incumbent is also responsible for utilization review, coordination of acute inpatient denials, performs admission and concurrent reviews and communication with physicians and payers regarding the medical necessity for services.

Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations, and documentation improvement opportunities.

This position also provides information (certified LOS and reimbursement issues) to the care team (RN, physicians, and case manager) as needed to ensure the appropriate and timely disposition of the client.

The Utilization Management RN, documents all chart and phone reviews, identifies and communicates potentially avoidable/non-reimbursed days, quality indicators (such as readmissions). Delivers non-covered letters as set forth by payer and/or regulatory compliance.

This position will be required to work a flexible schedule that may include evenings and weekends to provide coverage for the department as needed. This position participates in Quality Improvement initiatives.

Knowledge, Skills & Abilities

1. Strong interpersonal communication skills both verbal and written.

2. Knowledge of applicable regulatory requirements and community resources

3. Knowledge of continuous quality improvement process.

4. Philosophy consistent with the strategic plan of Renown Health

5. The ability to understand and resolve complex problems in a timely and effective manner using critical thinking skills.

6. The ability to keep current with new developments and acquire the needed knowledge for the position in order to keep skill sets up to date.

7. The ability to work under stress and to meet deadlines.

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. English. Appropriate education to obtain and maintain Registered Nursing licensure in the State of Nevada.

Experience:

Applicants with 1 year previous managed care and/or case management experience including acute hospital case management is preferred. Minimum of one-year in hospital setting required.

License(s):

Ability to obtain and maintain State of Nevada Registered Nurse license.

Certification(s):

Utilization or Case Management Certification preferred. Certification in Case Management (CCM), Certified Managed Care Nurse (CMCN), or ABQAURP HCQM is preferred.

Computer / Typing:

Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.