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Utilization Managment RN

Company: Benefis Health System
Location: Great Falls
Posted on: April 1, 2019

Job Description:

Serves as a physician consultant in the utilization review process to determine legitimacy of admission, treatment, and length of stay in the hospital to comply with government and insurance company reimbursement policies and leads the case management team for efficient and appropriate utilization of resources. Analyzes patient records against insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients and confers with medical staff and nursing personnel and other professional staff to identify appropriate level of care, length of treatment and length of stay. Refers cases to leadership and facility utilization review committee for review and course of action when case fails to meet admission standards.

DUTIES AND RESPONSIBILITIES:

Works in collaboration with physicians and multiple departments within the hospital to facilitate the most appropriate and efficient utilization of services.

Must possess familiarity of utilization review processes and Center for Medicare and Medicaid Services rules and regulations for reimbursement.

Must possess understanding of the complexity of various insurances and asks appropriate questions to verify coverage.

Educates patients, families, physicians and hospital staff about level of care criteria and appropriate parameters for documenting severity of illness and intensity of care to be provided.

Collaborates with and leads Care Coordinators to insure patient transition between levels of care, designated facilities, and community care.

Demonstrates competency in the referral of direct or indirect provision of individualized care of patients based on the patients assessed age and developmental needs.

Must be able to achieve client (patient, family, and physician) satisfaction given decreased resources, and increasing limitations on hospital utilization.

Must understand the appropriate level for hospice patients, understand appropriate placement in relation to Home Health, Transitional Care, provision of Rehab services, oxygen/medical equipment, and transportation needs.

Functions as a liaison between third party payors and responsible for effective public relations between hospital departments and community agencies.

Coordinators oversee all aspects of the utilization review process taking on many tasks including data collection, analysis, consulting and reporting.

Must perform other related duties and assigned tasks as requested, which may include: cross training and/or other job functions as temporary work loads and volumes require.

Must possess understanding of national health care trends and be able to analyze trends that impact the hospital and community settings.

Must assist in maintaining department records, reports, logs and files as required. Complete monthly statistical forms in a timely manner, if assigned.

Must participate in collecting data for process improvement as needed

Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.

Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.

Education/Experience Requirements:

Graduate of an accredited college or university with a Bachelor's Degree in Nursing required.

One to two years of utilization review and/or case management experience preferred.

Community Information: Great Falls has a city population of 60,000, with a draw of over 275,000 people in north central Montana. We experience mild winters and enjoy blue skies over 300 days per year. Great Falls is a wonderful and safe place to raise a family, with nationally ranked public schools and an average commute of under 12 minutes, making the quality of life in Great Falls unsurpassed in the Rocky Mountain West. Additionally, the Missouri River, a blue-ribbon fly-fishing destination, runs through the middle of town. Outdoor activities include camping, hiking, horseback riding, water and snow skiing, rock and ice climbing, boating, whitewater kayaking, off-road motorsports, upland bird and waterfowl hunting, and big-game hunting.

Benefis Health System: This is your opportunity to be part of an exceptional health system in a state that is well known for its beautiful four seasons and outdoor lifestyle. While enjoying the last best place, you'll have the added benefit of having access to Benefis Health System, one of the state's most modern and progressive healthcare facilities with 500+ beds and over 270 employed medical staff members representing more than 40 specialties. Our state-of-the-art facilities and cutting-edge technologies make Benefis an exceptional working environment and one of the "150 Top Places to Work in Healthcare" five years in a row.

Keywords: Benefis Health System, Great Falls , Utilization Managment RN, Healthcare , Great Falls, Montana

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