[Hiring] Utilization Management Specialist @Sanford Health

Role Description

Conduct level of care medical necessity reviews within patient’s medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable. Completes activities relating to determination of medical necessity, authorization, continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments.

• Workflows may include patient chart review, managing insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, and length of stay.
• Ensure validation of appropriate level of care for pre-admission surgical reviews prior to admission.
• Reviews include InterQual clinical decision support criteria to ensure appropriateness of medical services and effective cost control.
• Determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed.
• Collaborate with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes.
• Assist in documentation improvement practices for effective and appropriate services.
• Educate members of the healthcare team regarding trends, external regulations, and internal policies that affect resource utilization and potentially, prior authorization.
• Assist in monitoring the utilization of resources, risk management, and quality of care for patients in accordance with guidelines and criteria.
• Assist in report preparation, correspondence, and maintenance of appropriate records.
• Ensure services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements.
• Maintain working knowledge of payer standards for UM functions for authorization requirements.
• May assist with additional special projects related to work, upcoming initiatives, new organizational goals, and audits when delegated.
• Considered a resource to all team members and acts as a point of contact for guidance, training, and assisting with questions.
• Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs within interdepartmental and clinical units.

Qualifications

• Bachelor's degree in nursing preferred.
• Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
• Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing.
• Obtains and subsequently maintains required department specific competencies and certifications.

Requirements

• Opportunity to work remote.
• RN license required.

Benefits

• Salary Range: $27.50 - $38.50
• Work Shift: Day (United States of America)
• Scheduled Weekly Hours: 40
• Union Position: No