Utilization Management Review Nurse

Job Summary

Contractor position for ad hoc needs (PRN/0.0 hours) based on current demands of operational work. Role is designed to help fill gaps within service department and assignment could be variable day to day. Contracted employees are expected to work with minimal oversight and modified training on assignments matched to their distinct background and experience. Advanced or extended training may be approved based on needs of department. Volume and schedule of hours are pre-arranged with manager in advance and approved based on contractor's availabilities and needs of the department. The operations team works 24/7/365 mainly supporting healthcare systems with hospital sites. Therefore, hours have opportunity for extreme flexibility. We will consider contractors who are interested in working partial shifts, off-normal business hours, intermittent and variable commitment of hours, all the way up to full-time traditional M-F allotment of work dependent on business needs of our client(s).

The Utilization Management Review Nurse (UM RN) will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective utilization management, and ensuring revenue cycle efficiency. UM RN's oversee patient insurance authorization, compliance with governmental regulations related to hospital stays, prevention of and management of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the review and documentation process. This operational department conducts perspective, concurrent, and retrospective reviews for authorization of all Levels of Care (LOCs) and services, engaging with program managers, reviewing records to prove and support medical necessity, and liaising with individuals within healthcare system and hospital institutions. Long Tail works within a team approach with many specialists having a high-touch approach on each case. UM RNs are primarily responsible for completing clinical criteria reviews related to determining appropriate LOC for hospitalized patients and subsequently aligning necessary orders and patient status.

Education, Experience and Skills

• Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensure
• LOC reviews with use of criteria set(s):
• • Proficient or above with either Milliman (MCG) or Interqual (IQ) criteria set reviews
  • Proficient in all hospital LOC: Inpatient (IP) vs Observation (OBS) vs Outpatient in a Bed (OPIB) vs Not Medically Necessary
• Proficient in Avoidable Day/Delay (AD) determination and documentation.
• Proficient in processes for hospital medical necessity LOC and LOC status changes:
• • Observation/OPIB reviews, recommendations, and status determinations
  • Upgrade to Inpatient vs discharge vs AD
  • IP downgrades
  • Code 44 process
• Basic understanding of CMS Hospital-Issued Notices of Noncoverage (HINNs).
• Collaboration with Utilization Managment Phyician Advisors.
• Minimum 3 years' experience in hospital level utilization management.
• Minimum of 3 years of clinical nursing experience.
• Strong understanding of revenue cycle management and healthcare reimbursement. 
• Excellent communication, interpersonal, and teamwork skills. 
• Ability to work independently and make sound clinical and financial decisions. 
• Strong analytical and problem-solving skills. 
• Proficient in using healthcare information systems and technology. 
• Commitment to maintaining patient confidentiality and ethical standards. 

Preferred: 

• Bachelor of Science in Nursing (BSN) preferred. 
• CCM or ACM certification
• Epic EMR experience.
• • Account platform experience (billing and denials)
  • Work queue experience

Knowledge

• Knowledge of hospital revenue cycle and/or utilization review
• Proficient with principles of all payer types including managed care, Medicare/Medicaid, and private insurer reimbursement rules
• Knowledge of medical necessity criteria and payer reimbursement arrangements

Primary Job Duties

• Follow Standard Operating Procedure (SOP) for all activities assigned, escalate to designated leader if unsure of steps to take or procedure not readily available within accessible resources.
• Manage case/account reviews via client's EMR.
• Complete work within a team approach by finalizing and organizing tasks to the extent of specific assignment clearly and accurately so that next staff member can efficiently and effectively complete their portion of work.
• Use escalation pathways to resolve identified issues. 
• Document all activities and interactions clearly in the electronic utilization review record. 
• Enhance customer satisfaction among patients, families, physicians, internal and external partners, payors, and vendors. 
• LOC specific functions include:
• • Evaluate patient records to assess severity of illness and intensity of service. 
  • Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays. 
  • Conduct initial admission, continuing stay, observation and outpatient in a bed (OPIB) reviews for all patients. 
  • Collaborate with payor sources to communicate clinical information and secure approvals.
  • Consult with physicians, nursing staff and other clinical care team members
  • Effectively communicate need for change in status recommendations and follow up on order entry to ensure all adjustments are made as timely and accurately as possible.
• Adhere to policies, procedures, regulations, and standards governing the agency. 
• Maintain strict confidentiality according to Federal and State guidelines. 
• Uphold the Professional Code of Ethics. 
• Other duties as assigned. 

Work Context

A 100% remote work force will require very strong communication and remote relationship building skills. Contract workers are provided Azure Virtual Desktop (AVD) which will include any applications or software required for specific assignment. Contract workers are not provided hardware (i.e. computer) and are expected to utilize virtual desktop through their self-owned hardware.

Note

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.