RN - Utilization Review

Overview

Location : Remote - Applicants preferrably reside in UnityPoint Health's geographical areas of IA, IL, and WI.

Hours : Weekends Rotating 8 hr days one weekend, 12 hour days the other weekend

The RN Utilization Management Specialist, under the direction of the Manager, Utilization Management serves a key role in coordinating the organization’s interdisciplinary effort to assess and effectively use organizational resources and to track and minimize the inappropriate use of such resources.

Responsibilities

• Performs utilization management admission and continued stay outpatient reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources.
• Maximizes positive financial outcomes for patients and hospital by conducting timely ongoing chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care.
• Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making.
• Requests reviews with external and internal physician advisors as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status.
• Applies accepted potentially avoidable day logic to reviews so that accurate and timely data collection may occur.
• Serves as a resource to internal and external staff on issues related to utilization management
• Maintains current knowledge of Utilization Review Methodology, software, criteria and regulations governing various payment systems.
• Maintains current knowledge of the Unity Point Health Utilization Management Plan.
• Maintains current knowledge of CMS rules (e.g. Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement.
• Works with physicians regarding utilization issues as needed.
• Provides information to Denials staff as requested

Qualifications