Utilization Management Nurse (RN)

• Current Saint Francis Employees - Please click HERE to login and apply. Full Time Days Prior Utilization Management experience is preferred. Saturday, Sunday and Monday-6:45am-7:15pm Job Summary: Provides administrative and clinical support to the hospital and treatment teams throughout the review of patients including, but not limited to their placement in various levels of care and receipt of necessary services. The Utilization Management (UM) Registered Nurse will communicate with providers the details of reimbursement issues and participate in treatment teams, Patient Care Committee, and the Utilization Review Staff Committee by providing data and contributing to the improvement of internal processes. Minimum Education: Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom or Masters degree in Nursing. Licensure, Registration and/or Certification: Valid multi-state or State of Oklahoma Registered Nurse License. Work Experience: Minimum 2 years of related experience in an acute care setting. Knowledge, Skills and Abilities: Ability to organize and prioritize work in an effective and efficient manner. Effective interpersonal, written, and oral communication skills. Demonstrated ability to integrate the analysis of data to discover facts or develop knowledge, concepts, or interpretations.
• Ability to be detail oriented as required in the examination of numerical data.
• Ability to synthesize clinical case data into concise summaries. Working knowledge of Microsoft Word, Excel and Access in the preparation of correspondence and reports.

Essential Functions

and Responsibilities: Gathers, prepares and supplies required clinical/treatment information needed to obtain authorization within the review interval(s) time requirements

Participates in treatment team and/or Patient Care Committee by providing information about eligibility, benefits, and criteria for the selected level of care Assists in discharge planning, as needed

Identifies QI Triggers for individual patient situations, reporting them promptly to the UM Manager, appropriate clinicians and Process Improvement/Quality Director

Reviews eligibility and benefits of patients to validate accurate level of care utilization Investigates and prepares appeals for insurance companies when denial of reimbursement is related to medical necessity or to other treatment issues

Participates in quality-of-care and UM process improvement on an ongoing basis and assists with development of the UR Staff Committees process improvement goals Provides staff education to further the goals of UR

Decision Making: The carrying out of non-routine procedures under constantly changing conditions, in conformance with general instructions from supervisor Working Relationship: Works directly with patients and/or customers

Works with internal customers via telephone or face to face interaction Works with other healthcare professionals and staff Works frequently with individuals at Director level or above

Special Job Dimensions: None Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job

This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties Utilization Review Management - Yale Campus Location: Virtual Office, Oklahoma 73105 EOE Protected Veterans/Disability