ED Utilization Management Nurse

Job Details

What You Will Do

Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks to result in:
- Support of positive patient health care outcomes
- Increased patient/health care team outcomes and satisfaction
- Improved inpatient throughput and appropriate length of stay
- Improved communication, awareness and adherence to regulatory requirements associated with utilization
- Support for inappropriate level of care and decreased inpatient bed day denials
- Continuity and coordination of care
- Appropriate and timely authorization for level of care
- Decreased denials
- Appropriate reimbursement
Performs and documents timely and accurate concurrent review of records and discusses plan of care with ED physicians to support the decision making process with regard to LOC decisions inpatient admission or outpatient observation services. (60%)
- Supports effective and timely communication of the physician decision regarding inpatient admission or outpatient observation services for accurate registration status, and delivery of appropriate notices to patient when required (ie IMM delivered by registration staff).
Conducts all CM activities with a focus on continuous quality improvement in a manner that is supportive of UHC quality initiatives and in compliance with applicable regulatory requirements.

Additional Responsibilities

Performs other duties as assigned.
Complies with all policies and standards.
For specific duties and responsibilities, refer to documentation provided by the department during orientation.
Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

Hours are 10pm-10:30am, 2 days/week, working every 3rd weekend and rotating holidays

Education

Work Experience

3+ years Of clinical experience (acute care) (Required)
1+ years Of experience in utilization management/case management in an acute care setting (Required) or Experience as an ED nurse (Preferred)
Experience in ED utilization management/case management (Preferred)
Experience with Interqual or Milliman criteria (Preferred)

Knowledge, Skills, & Abilities

Must have sound clinical knowledge base of the population to be served (Required proficiency)
Knowledge of Medicare, Medicaid and commercial payer regulations. (Preferred proficiency)
Detail-oriented and organized, with good analytical and problem solving ability. (Required proficiency)
Notable client service, communication, presentation and relationship building skills. (Required proficiency)
Ability to function independently and as a team player in a fast-paced environment. (Required proficiency)
Must have strong written and verbal communication skills. (Required proficiency)
Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.). (Required proficiency)
Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines. (Required proficiency)
CM software proficient. (Preferred proficiency)

Licenses and Certifications

Registered Nurse (RN), Ohio and/or Multi State Compact License Upon Hire (Required)
CM certificate (Preferred)

Physical Demands

Travel Requirements