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Utilization Management Nurse - PRN/Casual

Children's Hospital & Medical Center - Omaha locationOmaha, NE
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271 positions
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271 positions
info linkReport a probelm Originally Posted : January 05, 2022

Details

Salary
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Job Location
Omaha, NE, United States

Description

Were searching for a Utilization Management Nurse is a specialty area of Nursing Case Management (NCM) and is responsible for reviewing and assessing all admissions for medical necessity utilizing standardized criteria that demonstrates the appropriate intensity of service for the severity of illness. UM includes retrospective and concurrent clinical reviews with third-party payors and actively collaborates with NCM and physicians to evaluate the medical plan, length of stay, avoidable days and appropriate use of inpatient and observation status. UM is responsible for all facets of denial management due to medical necessity and works collaboratively with patient accounts, the physician advisor, and NCM in various aspects of denial management. UM will serve as a liaison for NCM and the Access Center and be responsible for communicating third-party payor process changes to the appropriate departments.

Essential Functions

  • Reviews the appropriateness of all observation and inpatient admissions utilizing approved inpatient care criteria guidelines.
  • Notifies admitting physician and NCM of all inpatient admissions not meeting acute care guidelines.
  • Works directly with NCM physician advisor.
  • Guides admitting physician in protocols for conducting physician to physician review with third-party payers.
  • Appropriately documents all relevant communications in EPIC.
  • Ensures appropriate utilization of observation and inpatient status from admission to discharge.
  • Monitors all patients and works with physician to perform status conversions as appropriate.
  • Documents all discharges and assesses appropriateness of patient status.
  • Notifies appropriate members of interdisciplinary team of all status changes.
  • Ensure assigned length of stay (LOS) is appropriate.
  • Provides concurrent and retrospective reviews as needed to secure coverage of all inpatient days for patients currently admitted.
  • Maintains electronic documentation for all UM activities.
  • Communicates to NCM when impacts are identified to the patients plan of care.
  • Responsible for all facets of inpatient denials due to lack of medical necessity.
  • Communicates and documents all potential denials and non-covered days.
  • Tracks denials using department process.
  • Participates in various aspects of the revenue-cycle.
  • Collaborates with the NCMs to identify, document, and trend Avoidable Days.
  • Acts proactively at any point along the inpatient episode to ensure reimbursement is optimized (throughput).
  • Ensures that extended LOS are minimized.
  • Responds to trends discovered in recovery audits.
KNOWLEDGE, SKILLS AND ABILITIES Knowledge of:
  • The basic principles of healthcare resource management.
  • Clinical pathways and trajectories of pediatric diagnosis.
  • Basic rules and regulations regarding payor requirements.

Skills

  • Good communication skills with members of the interdisciplinary team.
  • Critical thinking skills.
Abilities
  • Must demonstrate positive interpersonal relationship skills with individuals and groups in a wide variety of settings.
  • Skills in negotiation and problem solving with utilization management.
  • Should be a creative, flexible, risk taker.
EDUCATION AND EXPERIENCE
  • Bachelors degree from an accredited college or university in nursing required or equivalent work experience.
  • Minimum 5 years in nursing required, preferably in a pediatric setting.

CERTIFICATIONS/LICENSURE REQUIREMENTS

  • Current and valid Nebraska RN license/RN Compact license required.
  • Certification in a nationally recognized case management/utilization management organization preferred.

EOE/Vets/Disabled

IND123

About Children's Hospital

When you work at Childrens, youre part of a treasured place of healing in the Omaha communityand beyond. Join our team of highly engaged, caring professionals who believe deeply in the organizations missionto improve the life of every child. We support equity, diversity and inclusion, and as you apply your skills and expertise to helping children, you too will have opportunities to grow your career. In 2021, well open the new Hubbard Center for Children, tripling our capacity to serve children.

When children are your everything, anything can be

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Children's Hospital & Medical Center - Omaha

Health Care/Wellness/Fitness
271 active jobs
locationOmaha, NE
clockFull-time
locationOmaha, NE
clockFull-time
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