UM​/RN Case Manager

Position Summary

Blended role that provides care coordination for patients in the Emergency Department along with medical necessity determination and recommendations for admission and Utilization Management concurrent reviews for ongoing medical necessity for hospitalized patients. The RN functions as a resource and advocate on behalf of the patient and family while assisting in the navigation of the health care delivery continuum by operationalizing multiple processes.

Maintains knowledge and skills in area of Utilization Management (UM), medical necessity, determination of proper patient admission status, and application of regulatory and reimbursement requirements of both government and commercial payers.

• Utilizes the organizational approved references and software programs to assess medical necessity
• Responsible for managing payer relations and requirements to achieve optimum reimbursement and patient outcomes
• Ensures CMS discharge standards are achieved
• Provides case management in collaboration with the medical staff, nursing, and ancillary departments throughout the hospital to ensure a safe, timely, transition to the appropriate level of care
• Assesses medical necessity of acute hospital admission and collaborates with multidisciplinary teams to promote proactive management of continuum of care
• Applies utilization review to evaluate appropriateness of care setting and level of care
• Collaborates with Physician Advisors, RN Case Managers, Social Workers and other members of the multidisciplinary team regarding admission status, medical necessity, utilization of resources, and insurance coverages and denials
• Performs concurrent and retrospective utilization reviews for ongoing stays and tracking of UM metrics related to extended length of stays
• Assures utilization management compliance of CMS regulations and Conditions of Participation
• Participates and collaborates with denials and appeals committee
• Performs other related duties as assigned
• Familiar with standard concepts, practices, and procedures within the field
• Relies on experience and judgment to plan and accomplish goals
• Regular and predictable attendance is an essential job function
• Competent to meet age specific needs of the unit assigned

• Graduate of a nationally accredited Nursing program
• State of Idaho Registered Nurse or licensure pending as documented by temporary licensure OR current RN licensure from a state participating in the "multistate privilege to practice" compact with Idaho
• Licensed RN with a minimum 3 years’ patient-facing RN experience at time of hire, ADN or diploma required; BSN or higher preferred
• All non-BSN RN's with less than 3 years’ patient-facing RN experience at time of hire are required to be enrolled in a baccalaureate (or higher) degree program in nursing within 1 year of employment, with completion within 3 years of hire
• Minimum 3 years clinical practice experience required
• 1 to 3 years of case management, utilization review, and critical care experience preferred
• Current Accredited Case Manager (ACM), Certified Case Manager (CCM), Certified Professional Utilization Review (CPUR) or Case Management Administration Certification (CMAC) preferred
• MCG certification required within 12 months of hire
• Must be available to work rotational weekends as per department schedule
• Excellent communication, organizational and interpersonal skills. Ability to work independently and manage time and decisions
• Proficiency with standard software applications including spreadsheets and word processing required

• Must be able to maintain a standing and/or sitting position
• Typical equipment used in an office job
• Repetitive movements

• Kootenai Health offers comprehensive medical plan options, including options for fully paid employer premiums for our full-time employees. For part-time employees, we offer the same plan options with affordable part-time premiums. In addition to medical insurance, we offer many voluntary benefits ranging from dental and vision to life and pet insurance. Kootenai Health also offers well-being resources and telemedicine service…