Utilization Management RN Internal Only

• Bachelors degree in Nursing or health care related field required.
• Current registration as a Licensed Registered Professional Nurse in New York State.
• Two (2) to three (3) years experience in case management discharge planning and/or progression of care in the acute-care setting. Understanding of New York State and Federal guidelines and insurance regulations.
• Minimum one (1) year Utilization Management experience preferred via industry clinical standards; ie. InterQual Milliman Care Guidelines.
• Leadership and management experience strong communication and interpersonal skills with the ability to mentor others and work effectively and collaboratively with nursing colleagues physicians and other healthcare professionals and administrators.

Responsibilities:

• Serves as a subject matter expert and leader in the ever-changing healthcare environment.
• Exercise a leadership style that fosters teamwork and collaboration with all hospital staff post-acute care facilities and providers.
• Effectively communicates with the patient family physician and health care team to ensure understanding of appropriate management and insurance guidelines and regulations.
• Determines appropriate level of care/status via clinical review within 24 hours of registration and/or placement.
• Daily review of all observation patients via InterQual or Milliman Care Guidelines.
• Collaborates with on-site insurance liaisons to determine appropriate reimbursement and appropriate status.
• Escalates reviews timely to physician advisor timely for lack of medical necessity and/or status discrepancies.
• Identifies opportunities to reduce cost of managing patient care without compromising outcomes.
• Issues denials to those that do not meet medical necessity criteria for hospital admission.
• Reports all variances through established outcome management and quality improvement processes.
• Identifies and tracks issues that contribute to status changes and denied hospital reimbursement.
• Identifies avoidable days via Midas that contributes to increased length of stay.
• Carries out work assignments within allotted time-frame.
• Accurately documents utilization management activities per policy.
• Communicates clearly with all members of patient family healthcare team and insurance liaisons.
• Continually updates knowledge of nursing theory insurance criteria current healthcare trends and available community resources.
• Responsible for yearly re-education on industry standard criteria;. InterQual/Milliman Care Guidelines.
• Maintains integrity and confidentiality of all data.

Ellis Medicine is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to and will prohibit discrimination on the basis of race creed color religion sex/gender (including pregnancy) age national origin disability (including pregnancy-related conditions) genetic information predisposition or carrier status military or veteran status prior arrest or conviction record marital or familial status sexual orientation transgender status gender identity gender expression reproductive health decisions domestic violence victim status known relationship or association with any member of a protected class and any other characteristic protected by applicable law violates federal state and where applicable local laws reproductive health decisions or source of payment consistent with applicable legislation and to comply with the laws pertaining thereto.

Salary Range: $36.07-$54.10 /hour Pay is based on experience skills and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.