Utilization Management RN - Care Management at Legacy Health

, Oregon, United States -

Full Time

Start Date

Immediate

Expiry Date

10 Jun, 26

Salary

81.21

Posted On

12 Mar, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Management, Care Coordination, Medical Necessity Criteria, Regulatory Requirements, Insurance Rules, Admission Reviews, Continued Stay Reviews, Clinical Information Flow, Third Party Payors, Denials Management, Statistical Analytical Skills, Transition Planning, CMS Guidelines, RN Licensure, Communication Skills

Industry

Hospitals and Health Care

Description

Overview The Legacy nursing philosophy focuses on patients and their families. Our nurses embody this philosophy in everything they do, as advocates, communicators, problem-solvers and caregivers. Their expertise is sought after and respected by our health care team. In short, they are the face of wellness at Legacy. Does this sound like an environment in which you could thrive? If so, we invite you to consider this opportunity. Responsibilities Serves as the interdisciplinary team expert and consultant regarding appropriate classification determinations. Ensures adherence to medical necessity criteria, regulatory requirements, and insurance rules. Acts as the primary status dispute prevention agent by performing admission and continued stay reviews as per government and commercial payor contractual requirements, to include the JCAHO Utilization Review Standard. Responsible for timely provision and flow of clinical information to and from third party payors and Care Management staff to ensure authorization of hospital services. Collaborates with the healthcare team, as well as Compliance and Revenue Cycle partners, on issues related to: continued stay, avoidable days, readmissions, RAC denials, second level reviews, outlier issues, and denials management. Serves as a contributing member of the Utilization Management Committee. Qualifications Education: Academic degree in nursing (BSN or MSN/MN) required; MSN/MN preferred. Experience: This position requires extensive knowledge of diseases, procedures, treatments, prognosis, medical necessity requirements and healthcare reimbursement. Minimum 2 years of acute care nursing required. Relevant experience in one or more of the following areas preferred: Utilization Management Care coordination of diverse patient populations Knowledge of levels of care throughout the health care continuum Denials prevention and management Utilization of Cortex (XSOLIS) platform Knowledge/Skills: Excellent organization, oral and written communication skills for effective interaction with patients, physicians, health care team members and representatives from insurance plans. Proficient statistical analytical skills for application of medical necessity criteria to patient stays and review of trends within healthcare. Knowledge of transition planning, health care reimbursement and utilization management processes. Knowledge of specific criteria and CMS guidelines for authorizations of continued inpatient stay or provision of outpatient services. Knowledge of regulatory issues. Ability to adhere to and implement regulations in an effective manner. Serve as a resource to all team members regarding regulatory issues. Keyboard skills and ability to navigate electronic systems applicable to job functions. Licensure Current Washington and Oregon RN licensure required. New applicants as well as current employees, will have six months to obtain either Washington or Oregon RN licensure. At least one licensure is required at the time of hire. Certification preferred in at least one of the following: Certified Professional in Healthcare Management (CPHM) Health Care Quality and Management (HCQM) Certified Case Manager (CCM) Accredited Case Manager (ACM) Pay Range USD $54.37 - USD $81.21 /Hr. Our Commitment to Health and Equal Opportunity Our Legacy is good for health for Our People, Our Patients, Our Communities, Our World. Above all, we will do the right thing. If you are passionate about our mission and believe you can contribute to our team, we encourage you to apply—even if you don't meet every qualification listed. We are committed to fostering an inclusive environment where everyone can grow and succeed. Legacy Health is an equal opportunity employer and prohibits unlawful discrimination and harassment of any type and affords equal employment opportunities to employees and applicants without regard to race, color, religion or creed, citizenship status, sex, sexual orientation, gender identity, pregnancy, age, national origin, disability status, genetic information, veteran status, or any other characteristic protected by law. To learn more about our employee benefits click here: www.legacyhealth.org/For-Health-Professionals/careers/benefiting-you

Responsibilities

This role serves as the interdisciplinary team expert for appropriate classification determinations, ensuring adherence to medical necessity criteria and regulatory requirements through admission and continued stay reviews. The individual is responsible for managing the flow of clinical information to third-party payors to authorize hospital services and collaborates on issues like avoidable days, readmissions, and denials management.