Rn Utilization Mgmt

Registered Nurse Utilization Management

Full Time, 80 Hours Per Pay Period, Day Shift

Covenant Health Overview:

Covenant Health is the region’s top-performing healthcare network with 10hospitals,outpatient and specialty services,and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned integrated healthcare delivery system and the area’s largest employer. Our more than 11,000 employees, volunteers, and 1,500 affiliated physicians are dedicated to improving the quality of life for the more than two million patients and families we serve every year.

Covenant Health is the only healthcare system in East Tennessee to be named a Forbes “Best Employer” seven times.

Position Summary:

The RN Utilization Management I will perform utilization management functions to include medical necessity reviews to promote a utilization management program that operates 24 hours a day 7 days a week. Exhibits extraordinary leadership and professionalism in role. Prepares and reviews necessary documentation for insurance utilization management processes and coordinates communication between members of the UM team to ensure timely follow through for status placement.

Collaborates with attending physician if ambiguous documentation pertaining to patient status placement requires clarification. Utilizes electronic utilization management database for documentation of interventions and communications so as to ensure accurate reporting. Collaborates with patient account services, physicians, care coordinators, physician advisors and facility departments as related to utilization management. Communicates with hospital and payor medical directors in order to correctly determine the medical necessity of patient status with a patient advocacy focus.

• Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise.
• Maintains accurate records of all communications and interventions related to utilization management.
• Exhibits effective verbal and written communication skills in order to clearly present clinical and financial data to various audiences as necessary.
• Collaborates with UM Committee when applicable.
• Collaborates with payor utilization management liaisons and medical directors as applicable.
• Establishes effective rapport with other employees, professional support service staff, payors, patients, families and physicians.
• Intervenes in Peer-to-Peer meetings between physicians and payors as applicable.
• Completes daily work lists for utilization review meeting the time frames set forth by Covenant Health.
• Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
  • Promote patient advocacy
  • Promote quality of care and/or life
  • Promote cost effective medical outcomes
  • Promote appropriate admission status
  • Provide continuity of care between utilization management and care coordinators
• Coordinates/facilitates execution of notices (denials) of non-coverage when appropriate and communicates with key stakeholders to ensure that patient liability is correctly managed.
• Exhibits expertise in utilization management including but not limited to:
  • Knowing Medicare rules and regulations related to utilization
  • Knowing payor policies related to utilization management
  • Knowing Covenant Health’s Policies related to utilization management.
  • Keeping abreast of current changes affecting utilization management as applicable.
• Performs well on internal audits thus promoting a culture of professional expertise in utilization management.
• Provides monitoring and…