Utilization Review Registered Nurse at Monument Health

Rapid City, South Dakota, United States -

Full Time

Start Date

Immediate

Expiry Date

17 Jul, 26

Salary

94640.0

Posted On

18 Apr, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization review, Medical necessity review, Appeals management, Case management, Regulatory compliance, Clinical auditing, Patient status determination, Interdisciplinary collaboration, Healthcare regulations, Managed care contracts, Reimbursement procedures, Documentation review

Industry

Hospitals and Health Care

Description

Current Employees: If you are a current Monument Health employee, please apply via the internal career site by logging into your Workday Account and clicking the "Career" icon on your homepage. Primary Location Rapid City, SD USA Department RCH Utilization Review Scheduled Weekly Hours 40 Starting Pay Rate Range $75,712.00 - $94,640.00 (Determined by the knowledge, skills, and experience of the applicant.) Job Summary Responsible for review and completion of denial/appeal requests. Stays current with Federal and State regulations regarding medical necessity for inpatient and observation hospitalizations. Will collaborate with Case Managers, Utilization Review Medical Directors, Corporate Compliance, Admissions and Patient Financial Services on patient status for accuracy of billing. Responsible for utilization review duties in collaboration with Case Managers. Completes audits for appropriate utilization of resources, develops/implements action plans when appropriate. Establishes goals and priorities consistent with mission and goals of Monument Health, as well as meets requirements of Joint Commission and other applicable federal, state and local regulatory and/or accrediting bodies. Monument Health offers competitive wages and benefits on qualifying positions. Some of those benefits can include: *Supportive work culture *Medical, Vision and Dental Coverage *Retirement Plans, Health Savings Account, and Flexible Spending Account *Instant pay is available for qualifying positions *Paid Time Off Accrual Bank *Opportunities for growth and advancement *Tuition assistance/reimbursement *Excellent pay differentials on qualifying positions *Flexible scheduling Job Description Essential Functions Advocates for payment of services, collaborates with physicians and the UR Committee. Facilitates the completion of medical necessity reviews for hospitalized patients and discharged medical record review as needed for appropriate patient status / service and plan of care. Assists in timely completion of denial reviews and assists to identify any trends. Promotes the optimal allocation of health dollars through accurate, effective and timely appeals. Stays current with the provider aspect of federal/state organization regulations related to inpatient and observation hospital level of care. Supports compliance with Utilization Review and regulatory guidelines. Identify trends related to compliance of regulations and collaborates with appropriate hospital personnel and external agencies to ensure appropriate process changes are implemented. Applies up-to-date information related to reimbursement procedures, managed care contracts. Fosters and role models an atmosphere of interdisciplinary collaboration and communication across the system and with both internal and external entities and disciplines. Elevates appropriate cases to leadership for review. Any other duties as assigned. Additional Requirements Required: Education - Completion of a nursing education program that is approved by a board of nursing Certification - Registered Nurse (RN) - South Dakota Board of Nursing Preferred: Education - Bachelors in Nursing Work Experience - 3+ years of Registered Nurse experience, 1+ year Utilization Review experience. Sedentary work - Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Job Category Patient Services Job Family Care Coordination Shift Requires the ability to work assigned schedules and hours as determined by the department Employee Type Regular 10 Monument Health Rapid City Hospital, Inc. Make a difference. Every day. Monument Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status. Learn more about a rewarding career at Monument Health. Click the "Get Started" button below to tell us more about yourself.

Responsibilities

The Utilization Review RN is responsible for conducting medical necessity reviews and managing denial/appeal requests to ensure accurate billing and resource utilization. They collaborate with case managers, medical directors, and compliance teams to maintain adherence to federal and state regulatory standards.