Nurse Clinician - Utilization Management

University of Iowa Health Care,
Care Coordination Division
- Utilization Management is seeking two (2)
Nurse Clinicians to functions as clinical nurse experts and clinical coordinators as the nurse liaison to physicians, patients and administration. The role will partner with the interdisciplinary health care team to ensure reimbursement of hospital admissions is based on medical necessity, and documentation is sufficient to support the level of care being billed. This role will conduct concurrent reviews as directed in the hospital’s Utilization Review Plan and review of medical records to ensure criteria for admission and continued stay are met and documented.

Along with other health care team members, monitors the use of hospital resources and identifies delays.

This role is approved for hybrid or remote work following the completion of probationary period and successful orientation.

• Perform a variety of admission, concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
• Utilize an evidenced-based clinical review screening criteria as a guide to support medical necessity determinations and refers cases with failed criteria to the Physician Advisor or appeal as necessary in accordance with the UM plan.
• Collaborate with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seek additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
• Validate commercial payer authorization within the contractual time frame at time of presentation, every third day or as needed (e.g., ED, Direct Admit, Transfers). Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary.
• Participate in the resolution of retrospective reimbursement issues, including appeals, third-party payer certification, and denied cases.
• Provide clinical information to relevant clinical team members regarding patient needs and/or newly identified issues, specifically working with the Utilization Management team.
• Serve as clinical resource to social services and other providers/nurse navigators, specifically regarding the compliance portion of the level of care.
• Review data specific to utilization management functions and reports as requested.
• Monitor effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, supporting the evaluation of the data, reporting results to various audiences, and implementing process improvement projects as needed.
• Participate in analyzing, updating, and modifying procedures and processes to continually improve utilization review operations.
• Work collaboratively with Nurse Navigators and Social Workers to expedite patient discharge.
• Participate in Care Coordination Division
  - Utilization Management initiatives or other projects according to departmental and organizational monitors.
• Perform basic administrative tasks related to the job as required by the Care Coordination Division to maintain accurate records and to ensure worker accountability/productivity.
• Maintain a highly acceptable level of professional conduct and respect for medical staff, coworkers, and hospital staff to foster a desirable image for the institution.
• Denote relevant clinical information to proactively communicate to payers for authorizations for treatments, procedures, and Length of Stay – send clinical information as required by the payer.
• Maintain current knowledge and understanding of hospital utilization review processes third party coverage with respect to Medicare, Commercial and Medicaid…