RN Wknd -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:

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

Work Experience:

Find it here.

Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.

Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College.

Carle Bro Menn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against…