RN Utilization Management - REMOTE

Job Description

Description:

Providence is calling a RN Utilization Management (Per-diem/Day-shift) to Providence California Regional Services.

This position is 100% remote - work from home. Requires working 1 weekend per month.

Apply today! Applicants that meet qualifications will receive an email with additional questions from our MODERN HIRE screening and interview system.

Please upload a current resume reflecting all relevant experience.

We are seeking a RN Utilization Management who will provide prospective, retrospective and concurrent utilization review for our LA ministries. Provide clinical reviews and medical records daily during admission for all payers as required by the health plans. Requires a strong clinical background blended with a well-developed knowledge and skills in Utilization Management, medical necessity and patient status determination.

The UM nurse effectively and efficiently manages a diverse workload in a fast paced, rapidly changing regulatory environment with excellent negotiation, communication, problem solving and decision making skills.

In this position you will:

• Review the Electronic Medical Record to perform admission reviews and continued stay reviews utilizing Interqual criteria to determine medical appropriateness of the initial admission and the continued stay. Faxes via EPIC clinical reviews and clinical documentation to payers daily to demonstrate medical necessity for the hospital stay
• Admission reviews are conducted within one business day of admission
• Continued stay reviews are provided daily for all HMO and Commercial payers
• Continued stay reviews are provided as directed by the Director, Utilization Management and Appeals
• Continued stay reviews are provided upon admission until the patient meets Acute IP LOC OR a secondary reviewer deems patients requires acute IP care for all Medi-Cal FFS beneficiaries
• Daily clinical reviews will be documented for all pending and restricted Medi-Cal patients
• Serve as a resource for California ministries
• Focus on patient class determination and escalates all cases with a patient class mismatch
• Perform continued stay reviews on current patients and communicates clinical information to payers in a timely manner such that the patient’s hospital days are authorized at the level of care being provided
• Collaborate with clinical leadership to develop a proactive approach to meeting clinical documentation standards
• Interpret and communicate regulatory standards and their implications to key stakeholders as appropriate
• Collaborate with ministries as appropriate in developing solutions to support clinical documentation improvement due to audit findings
• Proactively identify opportunities to improve care management related to medical necessity
• Escalate issues proactively, using sound judgment to determine the need for escalation
• Participate in a culture where fellow team members are focused on their contribution, and opportunity to impact the patient experience
• Management of denials while patients are in hospital to ensure peer to peer physician reviews are completed to prevent denials
• Identify, report cases and problems appropriate for secondary review to Director or Physician Advisor
• Advocate for appropriate provider documentation to accurately reflect patient severity of illness and risk. Collaborates with CDI
• Maintain collaborative relationships with providers, care management staff in the ministries, revenue cycle team and outside payers
• Participate in the development, implementation, evaluation and ongoing revision of initiatives to improve quality, continuity and cost effectiveness
• Provide clear and thorough documentation based on established standard work
• Provide orientation and mentoring to new staff
• Demonstrate ability to conduct age specific reviews for all age groups
• Pass Interqual IRR annually with a score of 90% or higher

Qualifications:

Required qualifications:

• Associate's Degree in Nursing
• Current RN license
• Minimum 1 year experience working in a remote UR environment or 3 years experience working as an acute hospital case manager
• Thorough knowledge of principles and practice of health care is required
• Excellent writing skills are required
• Through knowledge of evidence-based practices is required
• Requires excellent organizational and analytical skills with strong abilities for independent decision making and problem solving
• Requires excellent communication skills to interdisciplinary team

Preferred qualifications:

• Bachelor's Degree or Master's Degree in Nursing
• Case management certification
• Experience working with Interqual guidelines
• 2 years experience as a case manager in an acute care setting
• Experience in a multi-hospital and/or integrated healthcare system
• Working knowledge of regulations and provider contracts governing coverage of inpatient services (e.g., Medicare, Medi-Cal, Commercial Payers)

About the ministry you will serve:

For nearly 70 years, Providence Health & Services, Southern California, has provided quality and compassionate health care, building on a tradition of excellence, innovation, teamwork and outreach to those most in need. Anchored by five award-winning comprehensive medical centers, Providence provides a full spectrum of care that includes a range of specialties, signature services, outpatient and home care and the well-regarded Providence Medical Institute, a group of physicians and primary and urgent care clinics throughout the greater San Fernando Valley and South Bay. Providence is focused on providing the communities it serves with preventive care, education and leading-edge diagnostics and treatment. The organization includes numerous outreach programs. hospice and home care and even our own Providence High School, a Blue Ribbon college-preparatory campus.

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

https://www.providenceiscalling.jobs/rewards-benefits/

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: On Call

Shift: Day

Job Category: Case Management

Location: California-Burbank

Req ID: 319116