Duties & Responsibilities

POSITION OVERVIEW: (Primary Purpose of Position).

In accordance with Code of Federal Regulations (CFR), Title 42- Public Health, Section 482.30 (Conditions of Participation for Utilization Review), the Utilization Management provides clinical review of services furnished by the institution/by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs.

UM Staff Nurse act as a bridge between healthcare providers, patients, and insurance payers to manage costs and optimize care of LTACH patients, daily conduct concurrent, and retrospective (post-treatment) reviews using InterQual LTACH criteria or NYS DOH Medicaid criteria.

UM Nurse evaluates patient medical records and clinical data to ensure that healthcare services are medically necessary, appropriate, and delivered in the most efficient setting. Daily conduct and writes a short clinical summary in EPIC documenting the appropriate level of patient's care.

Collaborate with interdisciplinary teams and case managers to support smooth transitions of care and reduce avoidable hospital days.
ESSENTIAL FUNCTIONS: (List in order of importance to role and time spent on function)

• UM Staff Nurse evaluates patient medical records and clinical data to ensure that healthcare services are medically necessary, appropriate, and delivered in the most efficient setting. Daily conduct and writes a short clinical summary in EPIC documenting the appropriate level of patient's care. 2-3 hours
• Daily contact healthcare providers, patients, and insurance payers to manage costs and optimize care of LTACH patients, daily conduct concurrent, and retrospective (post-treatment) reviews using InterQual LTACH criteria or NYS DOH Medicaid criteria. 1-2 hours
• Daily Communicates with third party payors/insurers using insurance specific guidelines, conditions and time-frames by submitting all clinical reviews to the insurers for obtaining authorization for continued stay in LTACH and proper reimbursement. Communicates all anticipated denials to the Associate Executive Director and to the interdisciplinary care team, if necessary, initiates timely referrals to Physician Advisor. -2-3 hours
• Daily completes Patient Review Instrument and updates PRI data into EPIC for ALOC patients to process with timely discharges, provides information to insurers, providers, and internal staff regarding covered and non-covered benefits- 1-2 hours
• Daily interconnects with physicians involved in a patient's care to discuss medical status of the patents. Ensures timeliness in obtaining determinations from the insurance company and follows up on pending determinations. Maintains confidentiality of patient and hospital records and uses discretion when discussing patient and hospital matters. 30min -1 hour
• Monitor potential service denials, manage appeals, and ensure adherence to state, federal, and Medicare Advantage guidelines When needed, complete and submit all necessary clinical information pertaining to all discharge appeals with the QIO's such as Livanta and IPRO 2-3 hours 1-2 hours
• Clinical Reviews: Conduct prospective (pre-treatment), concurrent (during a stay), and retrospective (post-treatment) reviews using InterQual LTACH criteria or NYS DOH Medicaid criteria
• Insurance Authorizations: Evaluate and process requests for medical procedures, hospital admissions, continued stay, ALOC placement and obtaining the appropriate ALOC authorization with a proper ALC reimbursement
• Discharge Planning: Collaborate with interdisciplinary teams and case managers to support smooth transitions of care and reduce avoidable hospital days.
• Compliance & Denials: Monitor potential service denials, manage appeals, and ensure adherence to state, federal, Medicare Advantage guidelines and managed care regulations

Minimum Qualifications
1. A valid New York State license and current registration to practice as a Registered Professional Nurse in New York State; and
2. Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).
Special Note:
For assignments in Post-Acute Care ONLY, individuals meeting the following criteria may also be considered for appointment: Graduation from a nursing education program registered by the New York State Education Department (NYSED) as licensure qualifying for Registered Professional Nurse (RN) and has applied for licensure as an RN. These unlicensed individuals may be employed to practice under the immediate and personal supervision of a NYS licensed, currently registered, RN for up to 90 days immediately following graduation pending receipt of a limited permit, which selected candidates must apply for and receive within the same 90-day period. Once a limited permit is received, individuals can practice nursing, under the immediate and personal supervision of a NYS licensed, currently registered, RN at a NYC Health + Hospitals health care setting for up to one (1) year from the date of issuance of the limited permit. In addition, must hold or obtain through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).

Department Preferences

• Education: Bachelor degree in nursing required or Bachelor of Science in Nursing (BSN) preferred.
• Experience: 3-5 years of clinical bedside, experience 1 to 3 years in utilization review, case management, or managed care is a plus
• Skills: Working knowledge with electronic health records (e.g., Epic) and solid understanding of third-party payer regulations (Medicare/Medicaid), Being certified in completion of PRI s is preferable, strong communication skills

Additional Salary Compensation

In addition to base compensation, you may also receive the following based on collective bargaining:

An annual education differential if you currently possess an appropriate degree in nursing or an allied health discipline from an accredited college or university, as listed below:

• Bachelors in allied health discipline = $900
• Masters in allied health discipline = $1,200
• Bachelors of Science in Nursing (BSN) = $1,800
• Masters of Science in Nursing (MSN) = $2,000
• Doctorate in Education, Nursing Practice or PhD in Nursing (DNP) = $2,500

An annual certification differential ranging from $1,878 up to $4,878 if you currently hold appropriate certifications that are nationally recognized in the discipline or area of specialization for which you are employed.

An annual nursing experience differential ranging from $987 up to $8,190 for up to 10 years of experience if you have outside nursing experience as a Staff Nurse.

Benefits

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• Loan Forgiveness Programs for eligible employees
• College tuition discounts and professional development opportunities
• College Savings Program
• Union Benefits for eligible titles
• Multiple employee discounts programs
• Commuter Benefits Programs

If you wish to apply for this position, please apply online by clicking the "Apply for Job" button.