Shift: 4 10-hour shifts including Saturday & Sunday. 7am - 5pm
Work Arrangement: Hybrid - on-site required approximately once per month
Department: Utilization Management
Facility: Quarterdeck Building (2401 Lemone Industrial Blvd, Columbia MO) or Capital Region Medical Center (1125 Madison ST, Jefferson City MO)
Compensation:
• Base Pay Range: $68,265 - $100,401 per year, based on experience
DETAILED JOB DESCRIPTION
• Monitor unscheduled admissions to ensure appropriate patient type, timely notification of payor, and identify appropriate target LOS.
• Pre-certify/preauthorize process as assigned.
• Monitor 23-hour observation to ensure conversion to inpatient status if appropriate or discharge.
• Assist with denial and appeal process. Document avoidable delays/days.
• Monitor and develop plans of action for patients with extended LOS over that allowed by the benefit plan.
• Monitor admissions according to all third-party criteria.
• Perform retrospective reviews as necessary.
• Collaborate with payor reviewers to ensure appropriate utilization of resources.
• Provide formal and informal education/in-services to staff and physicians on utilization issues.
• Assist with the development/revision of policies, procedures, and service standards.
• Participate in ongoing efforts to improve the utilization management process and CQI activities as assigned.
• Maintain current knowledge of payor criteria/policies related to utilization of resources.
• Audit charts per request of Patient Accounts and Revenue Recovery. Compile data and statistics for monthly and annual reporting.
• Maintain clinical expertise in Medical-Surgical, Pediatric, and Psychiatric clinical care. Escalate payer issues to attending physicians and hospital leadership.
• Actively collaborates with the health care team regarding the course of care delivery to ensure timely discharge. Serve as liaison between the payer and the physician.
• Utilize medical discernment and critical thinking skills on a case-by-case basis as required for reimbursement maximization.
• Participate in formal education of payer criteria policies to medical students and Residents.
• May complete unit/department specific duties and expectations as outlined in department documents.
KNOWLEDGE, SKILLS, AND ABILITIES
• Excellent written and verbal communication skills.
• Knowledge of government and private insurance payer guidelines and regulations.
• Knowledge in the application of InterQual and/or Milliman Criteria.
REQUIRED QUALIFICATIONS
• Missouri Board of Nursing RN or Nurse Licensure Compact multi-state RN. When primary state of residency changes, compact state RNs must apply under new state of residency within thirty (30) days.
• Two (2) years of hospital clinical experience or two (2) years of current utilization review experience.
PREFERRED QUALIFICATIONS
• Experience in tertiary care and/or a teaching hospital.
• Experience in conflict resolution strongly desired.
• Additional license/certification requirements as determined by the hiring department.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. The employee may be required ambulate, remain in a stationary position and position self to reach and/or move objects above the shoulders and below the knees. The employee may be required to move objects up to 10 lbs.
