RN -UM​/Clinical Denial Mgmt

Overview

Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of the Carle Foundation Hospital. Facilitates the care of patient by insuring that admissions and continued days are medically necessary, cost-effective, and provided in the appropriate level of care to qualify for reimbursement.

The UM staff RN will function within the IP Care Coordination Department to ensure that the most cost-effective and appropriate use of health care services for patients treated by Carle Foundation Hospital. Ensures efficient patient flow and throughput. Initial assessment of all new patients for correct status (admission/observation/outpatient) based on UR medical necessity criteria. Performs concurrent reviews of all patient charts to ensure proper resource utilization as necessary to identify practice trends.

Keeping LOS within patients working DRG. Send clinical documentation to insurance companies per their request. Communicate with physicians on status changes and documentation. Refers cases for secondary review when appropriate. Refers cases for escalated medical review when services do not meet medical necessity criteria and/or appropriate level of care. Documents utilization reviews/issues in appropriate locations, including but not limited to case management/utilization review software.

Track Avoidable days. Educates and assists physicians in resource utilization. Participate in extended care reviews and attend meetings. Review cases for potential quality indicators and refers to UM Leadership. Works with Appeal staff to actively appeal cases concurrently and retrospectively. Strong attention to detail is required, as to minimize any misunderstandings regarding services authorization of or denial of services. Possess a working knowledge of Carle's organization and IPCC operations and administrative standards and policies.

Expert with acute level of care criteria. Apply severity of illness and intensity of service to determine appropriateness of care. Excellent interpersonal communication and the ability to interact with healthcare professionals in all disciplines. The ability to effectively communicate with physicians, payers, and hospital staff in a non-confrontational manner and provide excellent customer service. Ability to build rapport with medical staff, hospitalists services, and hospital leadership to obtain collaboration necessary to achieve desired UM outcomes.

Strong data management and computer skills (Word, Excel, Outlook, and EPIC Case Management software).

Certifications:

Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR).

Education:

Associate's Degree:
Nursing;
College Diploma:
Nursing.

Work Experience:

(not specified).

The compensation range for this position is $35.87 per hour - $58.37 per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered to a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model.

Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization.