RN - Utilization Management
US-OR-
Job ID: 24-38023
Type: Part Time - Benefitted
Homebased EE Oregon
Overview Relocation Assistance Available
The Legacy nursing philosophy focuses on patients and their families. Our nurses embody this philosophy in everything they do, as advocates, communicators, problem-solvers and caregivers. Their expertise is sought after and respected by our health care team. In short, they are the face of wellness at Legacy. Does this sound like an environment in which you could thrive? If so, we invite you to consider this opportunity.
This is a remote position - incumbents , who reside in Oregon or Washington only, may work at home, on the road or in a satellite location for all or part of their workweek . There may be occasional situations that require work to be performed on-site at an assigned Legacy Health location.
All new hires to Legacy are required to come to a designated Legacy Health office location in Portland, Oregon prior to their start date for a new hire health assessment and to complete new hire paperwork. This position may require initial training and orientation to be site-based, before transitioning to the remote schedule.
Responsibilities Serves as the interdisciplinary team expert and consultant regarding appropriate classification determinations. Ensures adherence to medical necessity criteria, regulatory requirements, and insurance rules. Acts as the primary status dispute prevention agent by performing admission and continued stay reviews as per government and commercial payor contractual requirements, to include the JCAHO Utilization Review Standard.
Responsible for timely provision and flow of clinical information to and from third party payors and Care Management staff to ensure authorization of hospital services.
Collaborates with the healthcare team, as well as Compliance and Revenue Cycle partners, on issues related to: continued stay, avoidable days, readmissions, RAC denials, second level reviews, outlier issues, and denials management. Serves as a contributing member of the Utilization Management Committee
Qualifications Education:
Academic degree in nursing (BSN or MSN/MN) required; MSN/MN preferred. Current Washington and Oregon RN licensure required. New applicants as well as current employees, will have six months to obtain either Washington or Oregon RN licensure. At least one licensure is required at the time of hire.
Certification preferred in at least one of the following:
Certified Professional in Healthcare Management (CPHM)
Health Care Quality and Management (HCQM)
Certified Case Manager (CCM)
Accredited Case Manager (ACM)
Experience:
This position requires extensive knowledge of diseases, procedures, treatments, prognosis, medical necessity requirements and healthcare reimbursement. Minimum 2 years of acute care nursing required. Relevant experience in one or more of the following areas
preferred:
Utilization Management, Care coordination of diverse patient populations, Knowledge of levels of care throughout the health care continuum
Denials prevention and management, Utilization of Cortex (XSOLIS) platform
- Five years acute care nursing experience required.
- Five years of healthcare utilization management experience preferred.
- Familiarity with office automation technology preferred.
- Quality assurance, project management, leadership and training skills
- Knowledge/Skills:
- Excellent organization, oral and written communication skills for effective interaction with
patients, physicians, health care team members and representatives from insurance plans.
Proficient statistical analytical skills for application of medical necessity criteria to patient
stays and review of trends within healthcare.
Knowledge of transition planning, health care reimbursement and utilization management
processes.
Knowledge of specific criteria and CMS guidelines for authorizations of continued inpatient
stay or provision of outpatient services.
Knowledge of regulatory issues. Ability to adhere to and implement regulations in an
effective manner. Serve as a resource to all team members regarding regulatory issues.
Keyboard skills and ability to navigate electronic systems applicable to job functions. - Excellent analytical skills to perform analysis and provide recommendations on charge capture and documentation.
- Excellent documentation skills.
- Strong written and verbal communication skills to work directly with all levels of LHS staff, management and physicians, as well as liaison with consultants and vendors.
- Strong organizational and prioritization skills.
- Demonstrated knowledge of billing process including registration, authorization, and insurance denials.
- Demonstrated knowledge of billing/collection rules and regulations.
- Ability to work with credibility and effectiveness with medical and administrative staff.
- Ability to withstand varying job pressures and organize and prioritize related tasks.
- Ability to work efficiently with minimal supervision, exercising independent judgment within stated guidelines.
- Ability to perform the competencies and essential functions of the job as outlined.
GENERAL ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS
• Reviews hospital admissions using approved criteria to verify documentation of
appropriateness of admission and classification determination. Refers cases to
secondary reviewer as needed.
• Collaborates with patient's attending physician regarding level of care and medical
necessity determinations. Obtains physician second level review as needed.
• Ensures that the appropriate classification order is present in each medical record
and monitors for compliance with Medicare's Inpatient Only list.
• Reviews medical charts for concurrent review purposes to verify documentation of
the plan of care and that the patient's response to this treatment justifies the need
for continued hospitalization.
• Communicates with representatives of insurance plans to provide required
documentation of medical necessity and obtain authorization for hospital days.
• Collaborates with the healthcare team and serves as the point person to
communicate ongoing information regarding authorized days, classification
changes, regulatory concern or denial issues.
Communicates directly with patients and families as needed to notify and educate
on issues pertaining to utilization management including observation classification,
medical necessity, insurance regulations, denials and appeals etc.
• Communicates to and educates physician groups on issues of medical necessity
and regulatory issues pertaining to utilization management.
• Communicates with Patient Business Services (PBS) regarding questions of patient
classification, level of care, or denial issues.
• Informs appropriate Care Management staff and PBS of potential denials.
• Partners with denials management staff to provide expert advice on medical
necessity appeals.
• Concurrently identifies and screens for quality indicators, referring issues to
leadership when appropriate.
• Documents interactions with payors in the Care Management software to enhance
operation efficiencies.
• Maintains documentation of current authorizations.
• Collaborates system-wide to create solutions to utilization management issues
including medical record classification concerns, appeal processes, quality
improvement projects and other topics as they arise.
• Provides key metric and analysis of UM trends and patterns to the Care
Management team and Utilization Management Committee.
LEGACY'S VALUES IN ACTION:
Follows guidelines set forth in Legacy's Values in Action.
Equal opportunity employer/vets/disabled.
Compensation details: 48.28-72.12 Hourly Wage
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