RN - Utilization Management Specialist - Utilization Review - Part Time Days
Company: Sanford Health
Posted on: January 24, 2023
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Sanford Health is one of the largest and fastest-growing
not-for-profit health systems in the United States. We're proud to
offer many development and advancement opportunities to our nearly
50,000 members of the Sanford Family who are dedicated to the work
of health and healing across our broad footprint.
Facility: Bemidji Medical Center
Location: Bemidji, MN
Address: 1300 Anne St NW, Bemidji, MN 56601, USA
Job Schedule: Part time
Weekly Hours: 24. 00
Salary Range: $27.50 - $38.50
Conduct level of care medical necessity reviews within patient s
medical records. Performs utilization management (UM) activities in
accordance with UM plan to assure compliance with
accreditation/regulatory requirements. Completes/coordinates
activities relating to the implementation, ongoing evaluation, and
improvements to UM and/or prior authorization processes with
applicable. Completes activities relating to determination of
medical necessity, authorization, continued stay review including
diagnosis and procedural coding for working diagnosis related group
(DRG) assignments. Workflows may include patient chart review, and
assisting with and managing of insurance coverage and denials,
prior authorizations, scheduled procedures, same-day readmission
reviews, as well as length of stay. Ensure validation of
appropriate level of care for pre-admission surgical reviews prior
to admission. Reviews include InterQual clinical decision support
criteria to ensure both the appropriateness of medical services and
effective cost control. Ability to determine appropriate action for
referring cases that do not meet departmental standards and require
additional secondary review and/or escalation as needed.
May also be actively involved in collaborating with members of the
healthcare team to promote medically necessary resource utilization
and achievement of fiscal outcomes when appropriate. Collaborates
with physicians and other clinical professionals as needed to
assist in documentation improvement practices for effective and
appropriate services. Dynamic and tactful interpersonal skills,
particularly in relating to physicians and other health care
professionals. Educates members of the healthcare team regarding
trends, external regulations and internal policies that effect
resource utilization and potentially, prior authorization.
Assists the department in monitoring the utilization of resources,
risk management and quality of care for patients in accordance with
guidelines and criteria. Assist in report preparation,
correspondence, and maintenance of appropriate records. Ensure
services comply with professional standards, national and local
coverage determinations (NCD/LCD), centers for Medicare and
Medicaid services (CMS), as well as state and federal regulatory
requirements. Maintain working knowledge of payer standards for UM
functions for authorization requirements.
May assist with additional special projects related to work,
upcoming initiatives, new organizational goals and audits when
delegated. Considered a resource to all team members and acts as a
point of contact for guidance, training, and assisting with
questions. Demonstrate flexibility and adaptability where
scheduling may fluctuate due to communication needs within
interdepartmental and clinical units are required.
Bachelor's degree in nursing preferred. Graduate from a nationally
accredited nursing program required, including, but not limited to,
Commission on Collegiate Nursing Education (CCNE), Accreditation
Commission for Education in Nursing (ACEN), and National League for
Nursing Commission for Nursing Education Accreditation (NLN
Currently holds an unencumbered registered nurse (RN) license with
the State Board of Nursing. Obtains and subsequently maintains
required department specific competencies and certifications.
Sanford Health offers an attractive benefits package for qualifying
full-time and part-time employees. Depending on eligibility, a
variety of benefits include health insurance, dental insurance,
vision insurance, life insurance, a 401(k) retirement plan,
work/life balance benefits, and a generous time off package to
maintain a healthy home-work balance. For more information about
Total Rewards, visit .
Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an
individual with a disability and would like to request an
accommodation for help with your online application, please call
1-877- or send an email to .
Sanford Health has a Drug Free Workplace Policy. An accepted offer
will require a drug screen and pre-employment background screening
as a condition of employment.
Req Number: R-
Job Function: Care Coordination
Featured: No Associated topics: cardiothoracic, care, hospice,
intensive care, intensive care unit, mhb, registered nurse,
surgery, surgical, tcu
Keywords: Sanford Health, Fargo , RN - Utilization Management Specialist - Utilization Review - Part Time Days, Executive , Bemidji, North Dakota
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