ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: RN Utilization Management

REPORTS TO POSITION: Manager- Utilization Management

DEPARTMENT: Utilization Management

DATE LAST REVIEWED: November 2024

OUR VISION: Creating Americas healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

DEPARTMENTAL SUMMARY: The Utilization Management (UM) Department promotes and provides a centralized, collaborative multi-disciplinary approach to utilization management across St. Charles Health System (SCHS). The UM Department supports physicians and clinical staff in identifying and improving care processes and systems for establishing and ensuring medical necessity, appropriate utilization of services, supporting denial avoidance and recovery and compliance with all local, state and federal regulations.

ESSENTIAL FUNCTIONS AND DUTIES:

Acts as an interdisciplinary team member within the UM Department, may be responsible for providing cross coverage for roles and responsibilities of other UM team members to back-fill during earned time off and/or during backlogs due to peak volumes.

Performs pre-admission status recommendation review for multiple care settings as assigned (i.e. Emergency Department, Direct Admission/Transfer, and/or elective procedure), to communicate with providers status guidance based on available information.

Ensures appropriate patient status upon admission and manages patient status conversions, as appropriate.

Ensures completion of admission medical necessity reviews within 24 hours of admission.

Completes concurrent inpatient medical necessity reviews at a minimum of every three (3) days unless otherwise specified by payor.

Completes Observation medical necessity reviews at a minimum of every 12 hours (twice daily).

Completes Medicare extended stay reviews, as appropriate.

Assigns an initial working DRG & GMLOS upon completion of initial medical necessity review for IP admission and enters in EMR.

Completes discharge reviews and ensures completeness of all prior medical necessity reviews and authorizations; escalates concerns, as appropriate.

Identifies and escalates all 1MN and 2MN Medicare IP stays.

Collaborates with Care Management (CM) team, as appropriate (i.e. extended observation stays, patients no longer meeting medical necessity, status changes).

Collaborates with physicians, as appropriate (i.e. to address issues concerning medical necessity, status orders, appropriate level of care, peer-to-peer involvement, etc.).

Collaborates with payors, as appropriate (i.e. discuss status, changes in LOC, changes in pre-authorizations warranting reauthorization, etc.).

Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM), as appropriate.

Escalates Medical Necessity (patient status / LOC) concerns and other UM concerns to Physician Advisor or designated leader, as appropriate.

Assists with discharge appeal process, as appropriate.

Provides timely and continual coverage of assigned work area in order to ensure all accounts are complete.

Assists in the identification of Avoidable Days and communicates information with CM, as appropriate.

Complies with all documentation requirements.

Follows up on action items prior to the end of shift.

Maintains a working knowledge of payor contracts and regulatory requirements and UM specific changes (i.e. changes in authorizations, payor contracts, CMS, regulatory requirements).

Completes all tasks within department guidelines.

Adheres to the policies, procedures, rules, regulations and laws of the hospital and federal and state governing bodies.

Provides support regarding Medicare documentation requirements.

Obtains verbal admission orders from physicians and monitors for authorization by the physician.

Participates in the delivery of regulatory forms to patients when appropriate.

Communicates with insurance companies regarding the medical necessity of the admission and provides clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays.

Actively participates in clinical performance improvement activities.

Assists in the collection and reporting of resource and financial indicators including LOS, cost per case, avoidable days, resource utilization, readmission rates, concurrent denials, and appeals.

Supports the vision, mission and values of the organization in all respects.

Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organizations corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.

EDUCATION

Required: Graduate of an accredited school of nursing.
Preferred: Bachelors degree in Nursing or Health Care related field

LICENSURE/CERTIFICATION/REGISTRATION

Required: Current Oregon RN license
Preferred: Accredited Case Manager Certification (ACMA:ACM-RN). Commission for Case Manger Certification (CCMC:CCM), Case Management Nurse-Board Certified (CMGT-BC:ANCC).

EXPERIENCE

Required: Three (3) three years acute care clinical nursing experience
Preferred: Five (5) years clinical experience in acute care facility

Two (2) years Utilization Management experience, or equivalent professional experience

Two (2) years experience working in electronic health records

ADDITIONAL POSITION INFORMATION

Skills: Advanced critical thinking and conflict resolution skills, working knowledge of regulatory and survey standards (Medicare, Joint Commission); working knowledge of status determination criteria (InterQual or MCG) and ability to apply consistently according to interrater reliability techniques; working knowledge of rapid-cycle process improvement

General: Ability to effectively interact and communicate with all levels within St. Charles Health System and external customers/clients/potential employees.

Strong team working and collaborative skills.

Ability to multi-task and work independently.

Attention to detail.

Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal interactions.

Strong analytical, problem solving and decision-making skills.

Demonstrated ability and experience in computer applications, use of electronic medical record keeping systems and MS Office.

PERSONAL PROTECTIVE EQUIPMENT

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP