US - North Carolina - CHARLOTTE
November 6, 2024
Overview
Job Summary
Utilization Management RN supports medical necessity, revenue integrity and denial prevention while coordinating with members of the healthcare team and payors for authorization of appropriate level of care and length of stay for medically necessary services. Accurately conducts medical necessity reviews, utilizing the electronic medical record, in accordance with all state and federal regulations and the Utilization Management Plan. Advocates for the patient while balancing the responsibility of stewardship for their organization, and in general, the judicious management of resources.
Essential Functions
Physical Requirements
Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Must speak English fluently and write English in understandable terms
Education, Experience and Certifications
Bachelor's in Nursing from an accredited school of nursing, required.
Master's degree in business or healthcare related field, preferred. Previous utilization review experience preferred. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background preferred. Strong financial and analytical skills preferred. Appropriate Professional certification required within 3 years of hire and per Clinical Care Management Certification Guidelines.
Additional education, training, certifications, or experience may be required within the department by the department leader.
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