Registered Nurse-Utilization Management

$20,000 BONUS, PLUS RELOCATION ASSISTANCE!!

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Coordination of Care

Job Family

Nursing

Work Shift

Days (United States of America)

Responsible for performing the initial and concurrent Utilization Review determination on all patients admitted or placed in observation (Outpatient with Observation Services). Direct discussion with the physicians and advanced practice providers to determine medical necessity for admission and establish appropriate status and level of care requirements. Facilitates clinical guidelines and achievement of desired treatment outcomes in the most appropriate setting and the most cost‑effective manner.

Analyzes patient records to determine appropriateness of admission, treatment, and length of stay in a health care facility to comply with regulatory and payor reimbursement policies. Maintain compliance with regulatory changes affecting utilization management and performs utilization review in accordance with all state and federally mandated regulations. Works collaboratively with the Utilization Management Manager and payors to ensure that denials and appeals are tracked and responded to in a timely and appropriate manner.

• Performs initial admission reviews on all patients within one day of bedding, using the appropriate Inter Qual guidelines or in accordance with CMS rules and regulations for admission and medical necessity
• Reviews physician orders for level of care status against patient status in the hospital registration system to ensure accuracy
• Ensures the chart coincides with the review or CMS rules and regulations for appropriate level of care and status on all patients
• Adheres to Medicare Condition Code 44 process
• Issues Medicare Outpatient Observation Notice (MOON) promptly to ensure timely notification to patients
• Coordinates with registration/bed placement departments and physician’s office to assure pre‑certification authorizations and supporting documents are obtained when required
• Reviews patient medical records for third party payors and provides clinical information to support admission and continued stay review
• Send billing communication to the designated PFS and HIM team members to ensure accurate billing designation
• Assess and evaluate the medical necessity and appropriateness of ancillary testing, medications, treatment, and plan of care, discussing concerns with the involved case manager
• Representative and point of contact for the Medicare Appeal process
• Adheres to mandates, standards and policies and procedures as determined at the federal, state, health system and department level
• Promotes positive customer service and service orientation in the performance of position duties and responsibilities and interactions with patients, hospital staff and visitors
• Participate in quality improvement activities in the direction of the Leadership Team to improve processes and promote evidence‑based practice
• Other duties as assigned

• Associate’s degree in nursing required
• Bachelor’s degree in nursing preferred
• Registered Nurse with active North Carolina License or Compact State Licensure preferred
• Professional certification in Case Management or Utilization Management preferred

• 3 years’ experience in Acute Care Setting preferred
• Medical/Surgical and/or ICU experience preferred
• Case Management experience preferred
• Additional one year in managed care claims/reimbursement or other healthcare field preferred

• Critical thinking and clinical competence demonstrated at an above average level
• Excellent interpersonal communication and negotiation skills
• Self‑motivated, proven written, telephonic, and electronic communication skills, assertive and persuasive in interactions with customers, peers, management, and core staff served
• Ability to discuss a patient’s clinical, socio‑economic, and financial issues with physicians and patient and/or patient representatives
• Strong organizational and time management skills
• Proficiency with various computer programs, including Microsoft Office,…