[Hiring] Utilization Management RN @CommonSpirit Health

Role Description

As our UM RN (Utilization Management Registered Nurse), you will be responsible for ensuring the integrity of the adverse determination processes and accuracy of clinical decision-making, as it relates to the application of criteria and composition of compliant denial notices, to review medical records, authorize requested services, and prepare cases for physician review based on medical necessity.

• Partner with both the Pre-Service and In-Patient Utilization Management teams.
• Monitor and assure the appropriateness and medical necessity of care as it relates to quality, continuity, and cost-effectiveness.
• Conduct meticulous review of medical records and application of clinical guidelines.
• Facilitate optimal patient care while ensuring compliance and fiscal responsibility.
• Strategically ensure the integrity and accuracy of utilization management decisions.
• Demonstrate exceptional clinical judgment and maintain rigorous oversight of care appropriateness.
• Work remotely with provided equipment including a laptop, docking station, dual monitors, and accessories.
• Potential for on-call, weekend, and holiday shifts.
• Review designated requests for referral authorizations proactively, concurrently, or retroactively.
• Gather all information needed to make a determination and/or coordinate with the Medical Director as needed.
• Ensure compliance with turnaround times and accuracy standards.
• Ensure contracted providers are in place when authorizing.
• Coordinate with contracting to obtain appropriate contracts as deemed appropriate.
• Identify cases that require additional case management.
• Work with appropriate departments and internal staff to coordinate patient care.

Qualifications

• Three (3) years recent clinical experience.
• Graduate of an accredited RN program.
• Clear and current CA Registered Nurse (RN) license.
• Knowledge of nursing theory and ability to apply or modify as appropriate.
• Knowledge of ICD-10, CPT, HCPCS coding, medical terminology, and insurance benefits.
• Knowledge of legal and ethical considerations related to patient information, PHI, and HIPAA regulations.

Requirements

• Bachelors of Nursing (BSN) preferred.
• Previous inpatient Utilization Management (UM) experience strongly preferred.
• Experience with MCG strongly preferred.
• EZCap experience a plus.

Company Description

One Community. One Mission. One California.