Utilization Review RN
CHI Flaget Memorial Hospital

Overview:

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U. S. & from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U. S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Responsibilities

Job Summary / Purpose

Works collaboratively with physicians, staff and other health care professionals within his/her Division to review and address concurrent denials - technical, medical necessity, and others. The role includes providing the clinical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures, as well as excellent communication with payers, medical staff and revenue cycle. This includes reviewing referral authorization, concurrent reviews, and high dollar claims review. The Denials Management RN is an integral member of the health care team as well as the Divisional Care Management team. Collaborates with the Utilization Management team on daily case issues as well as system-wide quality improvement/performance improvement initiatives.

Essential Key Job Responsibilities

Performs reviews on all concurrent denials. Assesses and intervenes as indicated with payer, secondary physician reviewers and hospital medical staff to overturn denials.

Addresses care issues with Utilization Management and Denials Manager, Physician Advisor and Chief Medical Officer/Medical Director as

Coordinates identifying and reporting potential high dollar/utilization cases to finance department for appropriate reserve

Consults with physicians, health care providers and outside agencies regarding continued care/treatment or hospitalization.

Identifies and recommends opportunities for cost savings and improving the quality of care across the

Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside

Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the

Reviews any service denials and gathers necessary supporting documentation from chart audits and follows up according to

Assists in the identification and reporting of potential quality of care

Responsible for assuring these issues are reported to the Market Manager Utilization Management and Denials.

Provides backup for Utilization Management RNs if needed.

Work as an interdisciplinary team member with Divisional Care management departments.

Other duties as assigned by management.

Accountability for results:

• Understands and self-manages to support facility and system key performance goals.
• Identifies opportunities for improvement (at individual, hospital and system levels) and actively works to correct or improve

Qualifications

Required Education

• Bachelor of Science in Nursing required

Required Licensure and Certifications

• Current unrestricted license as a reqistered nurse in state(s) of practice is required

Required Minium Knowledge, Skills and Abilities

• Demonstrated experience in utilization
• Experience with Indicia (formally Milliman Care Guidelines) authorization criteria
• Must have excellent computer skills and ability to learn new
• Must have strong organizational (time management) skills, strong interpersonal skills, the ability to handle multiple priorities with strong attention to
• Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word.
• Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost).
• Ability to work autonomously within matrix environment without direct supervision or support.

Preferred Qualifications

• Will accept equivalent experience in lieu of degree if the candidate obtains his/her BSN within 3 years post
• Care Management certification (CCM or ACM) preferred.
• Minimum 3 years clinical experience as Registered Nurse (RN)
• Minimum 5 years utilization management experience preferred.
• Denials management experience preferred.

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