Utilization Management (UM) Nurse Clinical Reviewer - RN (New York - Remote)

Our client is changing the future of healthcare with its innovative AI and data analytics. Our client is a growing organization, ranked on Inc. 5000’s prestigious list of fast-growing private companies in America. After years with large healthcare firms, our clients’ leaders had the realization: we can create and apply industry-leading artificial intelligence and machine learning to unleash more objective truth in data to enable our customers to work smarter, not harder. Our client applies these advanced technologies to serve both providers and payers, and not at the expense of one or the other.

Description

Current or recent hospital experience is a must have. This position will have well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual is responsible for performing a variety of concurrent and retrospective UM-related case reviews and functions. This individual maintains current and accurate knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to UM. The UM Specialist effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.

Essential Functions

Coordinate and facilitate correct identification of patient status.
Facilitates optimal reimbursement through accurate certification and denial processes, including complete chart documentation ensuring that the appropriate admission status is ordered.
Coordinate and integrate UM functions.
Conducts initial admission based on utilization review medical necessity criteria.
Refers cases for secondary review when appropriate.
Collaborate with all members of the healthcare team, both internal and external.
Refers and consults with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.
Communicate with third party payers regarding patient clinical progress.
Participate in clinical performance improvement activities to achieve set goals.
Demonstrate positive and professional written, verbal, and nonverbal communication skills.
Apply advanced critical thinking and conflict resolution skills using creative approaches.
The responsibilities listed are a general overview of the position and additional duties may be assigned.

Qualifications

Education:

Registered Nurse
New York RN License

Experience:

Current or recent experience working in or for a hospital is a must have.
Minimum 5 years professional experience required.
Minimum 3-5 years utilization management and case management in a hospital setting
Knowledge of Medicare rules and regulatory standards
Excellent interpersonal communication, problem-solving, and conflict resolution skills.
Computer skills in word processing, database management, and spreadsheet desirable.
Knowledge in areas of: Medicare and Medicaid UM regulations, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management.

License & Certification:

Active RN New York license is a must

Working Environment and Travel Requirements

Remote work is typically in a normal office administrative environment involving minimal exposure to physical risks.
Position requires little to moderate physical activity. Mostly sedentary work exerting up to 10 pounds of force occasionally or a negligible amount of force to lift, carry, push, pull, or otherwise move objects. Work involves sitting most of the time, but may involve walking or standing for brief periods of time. No significant stooping is usually required.
Travel possible for training.

Candidates must successfully pass a background check and drug screen (if applicable) prior to beginning employment. Clients may also require additional screenings.

Our client is an equal employment opportunity employer. All employees of our client fall under the same security role, which includes access to sensitive information, including proprietary data and PHI.

ONECITY Professional Recruiting jobs

UM/UR Nurse Clinical Reviewer