Typical pay range: $39.29 - $55.35
ST. CHARLES HEALTH SYSTEM
RN Utilization Management
Manager- Utilization Management
Creating America’s healthiest community, together
the spirit of love and compassion, better health, better care,
Accountability, Caring and Teamwork
DEPARTMENTAL SUMMARY: The Utilization Management (UM)
Department promotes and provides a centralized, collaborative
multi-disciplinary approach to utilization management across St.
Charles Health System (SCHS). The UM Department supports physicians
and clinical staff in identifying and improving care processes and
systems for establishing and ensuring medical necessity,
appropriate utilization of services, supporting denial avoidance
and recovery and compliance with all local, state and federal
POSITION OVERVIEW The Utilization Management Registered
Nurse (RN) has well-developed knowledge and skills in areas of
utilization management, medical necessity and patient status
determination. The UM RN supports the UM program by developing
and/or maintaining effective and efficient processes for
determining the appropriate admission status based on the
regulatory and reimbursement requirements of various commercial and
government payers. The UM RN is responsible for performing a
variety of concurrent and retrospective UM-related reviews and
functions and for ensuring that appropriate data is tracked,
evaluated and reported. When screening criteria does not align with
the physician order or a status conflict is indicated, the UM RN is
responsible for escalation to the Physician Advisor or designated
leader for additional review as determined by department standards.
The UM RN is responsible for denial avoidance strategies including
concurrent payer communications to resolve status disputes.
Additionally, the UM RN monitors the effectiveness/outcomes of the
UM program, identifying and applying appropriate metrics,
evaluating the data, reporting results to various audiences and
designing and implementing process improvement projects as
This position does not directly manage any other caregivers.
ESSENTIAL FUNCTIONS AND DUTIES:
Acts as an interdisciplinary team member within the UM
Department, may be responsible for providing cross coverage for
roles and responsibilities of other UM team members to back-fill
during earned time off and/or during backlogs due to peak
Performs pre-admission status recommendation review for multiple
care settings as assigned (i.e. Emergency Department, Direct
Admission/Transfer, and/or elective procedure), to communicate with
providers status guidance based on available information.
Ensures appropriate patient status upon admission and manages
patient status conversions, as appropriate.
Ensures completion of admission medical necessity reviews within
24 hours of admission.
Completes concurrent inpatient medical necessity reviews at a
minimum of every three (3) days unless otherwise specified by
Completes Observation medical necessity reviews at a minimum of
every 12 hours (twice daily).
Completes Medicare extended stay reviews, as appropriate.
Assigns an initial working DRG & GMLOS upon completion of
initial medical necessity review for IP admission and enters in
Completes discharge reviews and ensures completeness of all
prior medical necessity reviews and authorizations; escalates
concerns, as appropriate.
Identifies and escalates all 1MN and 2MN Medicare IP stays.
Collaborates with Care Management (CM) team, as appropriate
(i.e. extended observation stays, patients no longer meeting
medical necessity, status changes).
Collaborates with physicians, as appropriate (i.e. to address
issues concerning medical necessity, status orders, appropriate
level of care, peer-to-peer involvement, etc.).
Collaborates with payors, as appropriate (i.e. discuss status,
changes in LOC, changes in pre-authorizations warranting
Communicates and collaborates with Patient Access, Patient
Financial Services (PFS) and Health Information Management (HIM),
Escalates Medical Necessity (patient status / LOC) concerns and
other UM concerns to Physician Advisor or designated leader, as
Assists with discharge appeal process, as appropriate.
Provides timely and continual coverage of assigned work area in
order to ensure all accounts are complete.
Assists in the identification of Avoidable Days and communicates
information with CM, as appropriate.
Complies with all documentation requirements.
Follows up on action items prior to the end of shift.
Maintains a working knowledge of payor contracts and regulatory
requirements and UM specific changes (i.e. changes in
authorizations, payor contracts, CMS, regulatory requirements).
Completes all tasks within department guidelines.
Adheres to the policies, procedures, rules, regulations and laws
of the hospital and federal and state governing bodies.
Provides support regarding Medicare documentation
Obtains verbal admission orders from physicians and monitors for
authorization by the physician.
Participates in the delivery of regulatory forms to patients
Communicates with insurance companies regarding the medical
necessity of the admission and provides clinical documentation and
reviews to insurance companies as requested for purposes of ongoing
authorization of hospital stays.
Actively participates in clinical performance improvement
Assists in the collection and reporting of resource and
financial indicators including LOS, cost per case, avoidable days,
resource utilization, readmission rates, concurrent denials, and
Supports the vision, mission and values of the organization in
Supports Value Improvement Practice (VIP- Lean) principles of
continuous improvement with energy and enthusiasm, functioning as a
champion of change.
Provides and maintains a safe environment for caregivers,
patients and guests.
Conducts all activities with the highest standards of
professionalism and confidentiality. Complies with all
applicable laws, regulations, policies and procedures, supporting
the organization’s corporate integrity efforts by acting in an
ethical and appropriate manner, reporting known or suspected
violation of applicable rules, and cooperating fully with all
organizational investigations and proceedings.
Delivers customer service and/or patient care in a manner that
promotes goodwill, is timely, efficient and accurate.
May perform additional duties of similar complexity within the
organization, as required or assigned.
Required: Graduate of an accredited school of
Preferred: Bachelor’s degree in Nursing or Health Care
Required: Current Oregon RN license
Preferred: ACM (Accredited Case Manager) through AMCA
(American Case Management Association; CCM (Certified Case
Manager); CCMC (Commission for Case Manger
Required: Three (3) three years acute care clinical
Preferred: Five (5) years clinical experience in acute care
Two (2) years Utilization Management experience, or equivalent
Two (2) years’ experience working in electronic health
PERSONAL PROTECTIVE EQUIPMENT
Must be able to wear appropriate Personal Protective Equipment
(PPE) required to perform the job safely.
ADDITIONAL POSITION INFORMATION
Skills: Advanced critical thinking and conflict
resolution skills, working knowledge of regulatory and survey
standards (Medicare, Joint Commission); working knowledge of status
determination criteria (InterQual or MCG) and ability to apply
consistently according to interrater reliability techniques;
working knowledge of rapid-cycle process improvement
General: Ability to effectively interact and communicate
with all levels within St. Charles Health System and external
Strong team working and collaborative skills.
Ability to multi-task and work independently.
Attention to detail.
Excellent organizational skills, written and oral communication
and customer service skills, particularly in dealing with stressful
Strong analytical, problem solving and decision-making
Demonstrated ability and experience in computer applications,
use of electronic medical record keeping systems and MS Office.
Continually (75% or more): Use of clear and audible
speaking voice and the ability to hear normal speech
Frequently (50%): Sitting, standing, walking, lifting 1-10
pounds, keyboard operation.
Occasionally (25%): Bending, climbing stairs, reaching
overhead, carrying/pushing or pulling 1-10 pounds,
Rarely (10%): Stooping/kneeling/crouching, lifting,
carrying, pushing or pulling 11-15 pounds, operation of a motor
Never (0%): Climbing ladder/step-stool,
lifting/carrying/pushing or pulling 25-50 pounds, ability to hear
whispered speech level.
Exposure to Elemental Factors
Never (0%): Heat, cold, wet/slippery area, noise,
dust, vibration, chemical solution, uneven surface.
Blood-Borne Pathogen (BBP) Exposure Category
No Risk for Exposure to BBP
Schedule Weekly Hours:
First Shift (United States of America)
Is Exempt Position?
NON CONTRACT RN
Scheduled Days of the Week:
Shift Start & End Time:
0800 to 1700