The Utilization Management Nurse reports directly to Utilization Review RN Coordinator. The UR Nurse supports the UR RN Coordinator in providing oversight and guidance to all utilization functions for the organization and is responsible for ensuring complaint utilization and cost-effective care delivery. The UR Nurse is responsible for tracking and monitoring the level of care from the ED through discharge and follows and addresses denials to assess effectiveness of documentation and billing practices from a utilization perspective. In collaboration with the patient/family, physicians, and the interdisciplinary team, the UR Nurse ensures the care delivery systems in place at SPH are utilized effectively and efficiently and engages the UR RN Coordinator with improvement ideas when deviations of best practice are noted. The UR Nurse serves as an advocate for the patient and family throughout the continuum of care and serves as a collaborative and supportive liaison and educator to providers and staff around utilization management principles.

KNOWLEDGE/EXPERIENCE: • Minimum of 3 years of acute care experience required. Experience with healthcare insurance or utilization management functions required. Excellent communication skills and presentation skills essential for success in this role. EDUCATION: • Clinical preparation. LPN or RN Preferred

LICENSE/CERTIFICATION/REGISTRY: Nursing licensure in the State of Montana. Certification in Case Management and/or Utilization Review desired

 APTITUDES: • Excellent interpersonal communication and negotiation skills. • Knowledge of community and system resources • Strong organizational and time management skills • Ability to work independently • Word, Excel and Meditech experience preferred

The professional is this role will be responsible for: 

1) UR/Insurance Denials/Appeals/Peer to peer Coordination: In a timely manner, reviews the previous day’s denial activity as identified by both electronic and paper denials, and take necessary steps to resolve the denials. This includes but is not limited to, assessing the denials by reaching out to the appropriate departments and contacting the appropriate insurance carrier for additional information. If it is determined an appeal is needed; gat her the pertinent records and/or documentation and submit the appeals, reconsiderations or adjustments. 

2) Stays current on insurance issues and proactively educates/notifies UR RN Coordinator of pertinent changes. 

3) Maintains confidentiality of hospital, patient and family information.

 4) Must be able to interact with various hospital staff and departments at all levels possessing positive communication skills , and compassionate competence. 

5) Applying medical knowledge and experience for prior authorization requests;

6) Performing detailed medical reviews of prior authorization request or assessment forms according to established criteria and  protocols;

 7) Manage incoming authorization requests and inquiries via email, fax, computer, telephone, or mail; 

8) Maintain accurate documentation on all requests and documenting in the appropriate computer application; 

9) Initiates and continues direct communication with health care providers involved with the care of the patient to obtain complete and accurate information; 

10) Serve as a resource to clients; 

11) Follow up on Peer to Peer requests including scheduling these to be completed between the facility and plan providers. 

12) Review insurance companies’ requests for change of patient status using InterQual or MCG guidelines then negotiates with insurers to obtain the maximum payment possible for the claim. 

13) Collaborates real-time with medical staff to assure correct admission status and confirm treatment goals, treatment plan, and clinical mileposts used to advance the treatment plan. 

14) Coordinates patient information to assure timely reviews according to UR work plan and follow-up with Optum (E.H.R.) physician consultants. 

15) Confirms admission diagnosis and correct admission status and identifies related quality measures to promote medical compliance.

 16) Collaborates with admitting physician, ED physicians, Hospitalists, Documentation Specialist and other ancillary staff to assist with the initial patient assessment and high risk screen for the purpose of resource management. 

17) Provides point-of-care coaching to the medical staff for documentation improvement and observance of quality indicators to support admission status and care plan.

 18) Consults with the clinical providers and leaders as necessary to resolve barriers through appropriate administrative and medical channels. 

19) Evaluates denials for appropriateness for appeals versus billing at an alternate level of care. 

20) Track and follow up on submitted appeals, adjustments and reconsiderations