Registered Nurse Utilization Management 1

Overview

Registered Nurse Utilization Management

Full Time, 80 Hours Per Pay Period, Day Shift

Covenant Health Overview:

Covenant Health is the region’s top-performing healthcare network with 10 hospitals, outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned integrated healthcare delivery system and the area’s largest employer. Our more than 11,000 employees, volunteers, and 1,500 affiliated physicians are dedicated to improving the quality of life for the more than two million patients and families we serve every year. Covenant Health is the only healthcare system in East Tennessee to be named a Forbes “Best Employer” seven times.

Position Summary:

The RN Utilization Management I will perform utilization management functions to include medical necessity reviews to promote a utilization management program that operates 24 hours a day 7 days a week. Exhibits extraordinary leadership and professionalism in role. Prepares and reviews necessary documentation for insurance utilization management processes and coordinates communication between members of the UM team to ensure timely follow through for status placement.  Collaborates with attending physician if ambiguous documentation pertaining to patient status placement requires clarification. Utilizes electronic utilization management database for documentation of interventions and communications so as to ensure accurate reporting.  Collaborates with patient account services, physicians, care coordinators, physician advisors and facility departments as related to utilization management. Communicates with hospital and payor medical directors in order to correctly determine the medical necessity of patient status with a patient advocacy focus.

Responsibilities

• Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer for those that require additional expertise.
• Maintains/validates accurate records of all communications and interventions related to utilization management.
• Exhibits effective verbal and written communication skills in order to clearly present clinical and financial data to various audiences as necessary.
• Collaborates with UM Committee when applicable.
• Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise.
• Maintains accurate records of all communications and interventions related to utilization management.
• Exhibits effective verbal and written communication skills in order to clearly present clinical and financial data to various audiences as necessary.
• Collaborates with UM Committee when applicable.
• Collaborates with payor utilization management liaisons and medical directors as applicable.
• Establishes effective rapport with other employees, professional support service staff, payors, patients, families and physicians.
• Intervenes in Peer-to-Peer meetings between physicians and payors as applicable.
• Completes daily work lists for utilization review meeting the time frames set forth by Covenant Health.
• Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
  • Promote patient advocacy
  • Promote quality of care and/or life
  • Promote cost effective medical outcomes
  • Promote appropriate admission status
  • Provide continuity of care between utilization management and care coordinators
• Coordinates/facilitates execution of notices (denials) of non-coverage when appropriate and communicates with key stakeholders to ensure that patient liability is correctly managed.
• Exhibits expertise in utilization management including but not limited to:
  • Knowing Medicare rules and regulations related to utilization
  • Knowing payor policies related to utilization management
  • Knowing Covenant Health’s Policies related to utilization management.
  • Keeping abreast of current changes affecting utilization management as applicable.
• Performs well on internal audits thus promoting a culture of professional expertise in utilization management.
• Provides monitoring and oversight of non-clinical utilization staff activities.
• Provides advice and counsel to non-clinical precertification staff.
• Assists with delayed claims review to determine appropriate number of observation hours as applicable in order for correct charges to be added to the patient’s account.
• Assist with insurance requested audits and provides information to supervisor related to inaccurate and/or missing documentation as applicable.
• Attends meetings as required and participates on committees as directed.
• Performs other related duties as assigned or requested.
• Motivates coworkers and promotes a team effort in accomplishing goals and deadlines with accuracy, dependability and professionalism.
• Supports, models and adheres to desired behaviors of the KBOS Constitution for caring which are; build a trusting environment by listening with an open mind and valuing different opinions; asking questions for understanding and allowing others to speak openly, do not gossip or criticize people behind their back, resolve conflicts, notice and express appreciation for good work and respect differences by listening with an open mind.
• Supports, models and adheres to the desired behaviors of the KBOS Constitution and Covenant Health for service which are; take ownership for our mistakes, resolve customer problems on the spot whenever possible, treat all people with respect and kindness, strive to meet or exceed customer expectations, collect and use customer feedback/data to improve processes and service and set an example for accountability and responsiveness: return e-mail and phone calls promptly, assure deadlines are met, keep commitments.
• Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives and participates in quality improvement initiatives as requested.
• Performs other duties as assigned.

Qualifications

Minimum Education:           

None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority.

Minimum Experience:         

Three (3) years of acute care nursing experience; a minimum of two (2) years of experience in area of assigned responsibility. Prefer recent utilization management or case management experience.

Licensure Requirement:      

Current licensure as a Registered Nurse (RN) as issued by the State of Tennessee. CCM/CPHQ certification preferred or equivalent expertise in area of Utilization Management as evidenced by performance.