The Utilization Management Nurse (UM RN) provides care coordination for a patient's hospital, long term acute care (LTAC), acute rehabilitation hospital, psychiatric or skilled nursing facility (SNF) stay. Working with the Interdisciplinary Care Team (IDT), the UM RN monitors the length of stay (LOS), the appropriate utilization of care, promotes quality, obtains clinical review, and plans/implements a participant’s discharge. Work can be done remotely.
- Responsible for the evaluation of the medical necessity of continuing acute inpatient or psychiatric stays, LTAC, acute rehabilitation and skilled nursing stays utilizing a defined criteria set.
- Utilizes clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
- Responsible for obtaining the information necessary to assess a participant’s clinical condition, identifies ongoing clinical care needs and ensures that participants receive services in the most optimal setting to effectively meet their needs.
- Collaborates with ESP interdisciplinary teams regarding management of members not meeting continuing stay criteria.
- Anticipates member’s post-discharge needs, managing transition of care or referring to Care Coordinator when appropriate.
- Maintains mandated timeframes, including those related to second level appeals.
- Uses Patient Ping (a real-time notification system that provides an alert when patients receive care in the ED, hospital or post-acute setting) to track participant disposition and work with providers to establish necessity of emergency room transfers.
Required/Preferred Education, Experience and Skills:
- Bachelor's Degree in Nursing required.
- Current, valid, and unrestricted MA Registered Nurse (R.N.) license.
- Minimum of 2-3 years of acute care clinical nursing experience required.
- Minimum of 3 years of recent experience in Utilization Review / Utilization Management preferred.
- 1-2 years of experience at a health plan or other Managed Care Organization (HMO/TPA/IPA/SCO, etc.) preferred.
- Experience using MCG/Milliman/InterQual criteria for medical necessity, setting and level of care, and concurrent patient management preferred.
- Basic Computer skills to include Microsoft Word, Excel, database use, data entry and Electronic Medical Record.
Harbor Health is an Equal Opportunity Employer M/F/V/D.
- Flexible Schedules
- Life Insurance
- Employee Events
- Professional Development
- Paid sick days
- Employee Referral Program
- Paid Holidays
- Flexible Spending Accounts
- Vacation/paid time off
- Medical, Dental and Vision
- Long Term Disability
Clinical Auditor / Utilization Reviewer