RN Utilization Management

Overview

Pay range: $47.35 - $71.03

Employer: ST. CHARLES HEALTH SYSTEM

Job title: RN Utilization Management

Reports to: Manager
- Utilization Management

Department: Utilization Management

Date last reviewed: November 2024

Our vision: Creating Americas healthiest community, together

Our mission: In the spirit of love and compassion, better health, better care, better value

Our values: Accountability, Caring and Teamwork

Departmental summary: The Utilization Management (UM) Department promotes a centralized, collaborative multidisciplinary approach to utilization management across St. Charles Health System (SCHS). The UM Department supports physicians and clinical staff in identifying and improving care processes and systems for establishing and ensuring medical necessity, appropriate utilization of services, supporting denial avoidance and recovery and compliance with all local, state and federal regulations.

The Utilization Management Registered Nurse (RN) has well-developed knowledge and skills in utilization management, medical necessity and patient status determination. The UM RN supports the UM program by developing and maintaining effective and efficient processes for determining appropriate admission status based on regulatory and reimbursement requirements of various commercial and government payers. The UM RN performs a variety of concurrent and retrospective UM-related reviews and functions and ensures that appropriate data is tracked, evaluated and reported.

When screening criteria do not align with the physician order or a status conflict is indicated, the UM RN escalates to the Physician Advisor or designated leader for review as determined by department standards. The UM RN uses denial avoidance strategies including concurrent payer communications to resolve status disputes. The UM RN monitors the effectiveness/outcomes of the UM program, identifies and applies metrics, evaluates data, reports results to various audiences and designs and implements process improvement projects as needed.

This position does not directly manage any other caregivers.

• Acts as an interdisciplinary team member within the UM Department; may provide cross-coverage for roles and responsibilities of other UM team members to back-fill during earned time off or backlogs due to peak volumes.
• Performs pre-admission status recommendation review for multiple care settings (e.g., Emergency Department, Direct Admission/Transfer, elective procedures) and communicates status guidance to providers based on available information.
• Ensures appropriate patient status upon admission and manages status conversions as appropriate.
• Ensures completion of admission medical necessity reviews within 24 hours of admission.
• Completes concurrent inpatient medical necessity reviews at least every three (3) days unless otherwise specified by payor.
• Completes Observation medical necessity reviews at least every 12 hours (twice daily).
• Completes Medicare extended stay reviews, as appropriate.
• Assigns an initial working DRG & GMLOS upon completion of initial medical necessity review for IP admission and enters in EMR.
• Completes discharge reviews and ensures completeness of all prior medical necessity reviews and authorizations; escalates concerns as appropriate.
• Identifies and escalates all 1MN and 2MN Medicare IP stays.
• Collaborates with Care Management (CM) team as appropriate (e.g., extended observation stays, patients no longer meeting medical necessity, status changes).
• Collaborates with physicians as appropriate (e.g., to address issues concerning medical necessity, status orders, appropriate level of care, peer-to-peer involvement).
• Collaborates with payors as appropriate (e.g., discuss status, changes in LOC, changes in pre-authorizations warranting reauthorization).
• Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM), as appropriate.
• Escalates Medical Necessity concerns to Physician Advisor or designated leader, as appropriate.
• Assists with discharge appeal process, as appropriate.
• Provides timely and continual coverage of assigned…