Utilization Review RN - Patient Bus Svs

Job Description

The Utilization Management RN reports directly to the Utilization Review RN Coordinator. This role supports the coordinator and other UR team members in providing all identified utilization review functions for the organization, ensuring cost‑effective care delivery.

• Stay current on insurance issues and proactively educate the UR RN Coordinator of pertinent changes.
• Maintain confidentiality of hospital, patient, and family information.
• Interact with various hospital staff and departments at all levels, demonstrating positive communication skills and compassionate competence.
• Apply medical knowledge and experience for prior authorization requests.
• Perform detailed medical reviews of prior authorization request or assessment forms according to established criteria and protocols.
• Manage incoming authorization requests and inquiries via email, fax, computer, telephone, or mail.
• Maintain accurate documentation on all requests in the appropriate computer application.
• Initiate and continue direct communication with health care providers involved with the care of the patient to obtain complete and accurate information.
• Follow up on Peer to Peer requests, including scheduling these to be completed between the facility and plan providers.
• Review insurance companies’ requests for change of patient status using MCG guidelines, then negotiate with insurers to obtain maximum payment possible for the claim.
• Collaborate in real time with medical staff to assure correct admission status and confirm treatment goals, treatment plan, and clinical milestones used to advance the treatment plan.
• Coordinate patient information to assure timely reviews according to UR work plan and follow up with physician consultants.
• Confirm admission diagnosis and correct admission status, and identify related quality measures to promote medical compliance.
• Collaborate with admitting physician, ED physicians, hospitalists, documentation specialist, and other ancillary staff to assist with the initial patient assessment and high‑risk screen for resource management.
• Provide point‑of‑care coaching to the medical staff for documentation improvement and observation of quality indicators to support admission status.
• Evaluate denials for appropriateness for appeals versus billing at an alternate level of care.
• Track and follow up on submitted appeals, adjustments, and reconsiderations.

• Work independently to provide coverage for UR activities during weekend days while other UR team members are out of the office.
• Complete comprehensive review of all admissions to SPH. These are evaluated for admission status.
• Follow up daily on all communication with the MD advisor or physician consultant(s) on any cases sent for physician review.
• Perform daily utilization reviews on all patients admitted the day prior.
• Conduct continued stay reviews daily.
• Document avoidable days of care within Epic.
• Using MCG severity of illness/intensity of service criteria, evaluate the patients’ status and need for acute care services to assure appropriateness of the admission status and communicate when needed with other UR team members.
• Work closely with hospitalist team providers, outside providers, and staff to assure patients admitted meet the appropriate criteria for status orders.
• Contact the attending provider for variations in status from that of criteria and/or physician advisor recommendations.
• Enter appropriate status orders into Epic as they are received for admission status changes deemed appropriate by the attending provider.
• Participate in orientation of new employees of the UR team.
• Work in harmony and unison with all personnel of St. Peter’s Health.
• Complete and/or attend all required educational offerings annually.
• Demonstrate ability to use electronic software applications related to UR activities.
• Operate copying machine, fax machine, computer, handling AV equipment, materials, and supplies.
• Perform other duties as assigned to ensure UR RN’s talents are utilized to better the organization.

• Minimum of three (3) years of acute care experience desired.
• Experience with healthcare insurance or utilization management functions preferred.
• Excellent assessment and analytical skills and an ability to effectively communicate with SPH team members and outside providers is an essential requirement for this role.

• Clinical preparation; RN required.

Nursing licensure in the State of Montana. Certification in Case Management and/or Utilization Review desired.

• Excellent interpersonal communication and negotiation skills.
• Knowledge of community and system resources.
• Strong organizational and time management skills.
• Ability to work independently.
• Word, Excel, and Meditech experience preferred.