RN Utilization Management

Company: Sanford Health
Location: Fargo
Posted on: September 25, 2024

Job Description:

Careers With Purpose

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: Carufel Building

Location: Fargo, ND

Address: 505 7th Ave N, Fargo, ND 58102, USA

Shift: 8 Hours - Day Shifts

Job Schedule: Full time

Weekly Hours: 40.00

Pay Info: ** experience credit added to wage

Job Summary**

Provides expertise and leadership to ensure effective resource management for patient care delivery across the care continuum for assigned patient populations.

This position primarily focuses on Utilization Management activities such as:

• Evaluate medical necessity, efficiency and appropriateness of health care services
• Admission & Continued Stay Medical Necessity reviews using MCG guidelines and/or InterQual criteria
• Prospective medical necessity reviews using MCG guidelines and/or InterQual criteria
• Prompt and effective management of payer denials and appeals
• Collaboration and consultation with secondary physician reviewers and appropriate referrals for secondary level review
• Detailed reviewing of medical records to help improve patient care/outcomes
• Educating physicians and health care team to improve utilization processes
• Communication and collaboration with the interdisciplinary care team to facilitate effective transitions in care
• Responsible for communications with insurance companies as well as obtaining prior authorization when required
• Identification and delivery of non-coverage notices as appropriate based on Medicare and payer rules and regulations
• Requires strong problem-solving, customer service, organization, critical thinking, communication and interpersonal skills
  Additional Information:
  
  • Monday Friday 0800-1630
  • Every 5th to 6th Weekend 0700-1530
  • 1-2 rotating holidays per year
  • Requires at least one year on-site work and may consider transition to remote work if demonstrating competency in productivity and quality as well as reliability and dependability and ability to be successful working independently. With involvement of the patient/family, collaborates with licensed practitioners and other inter-professional team members to provide care coordination, transitional care planning, facilitation and coordination of discharge needs. Enhances the quality of clinical outcomes and patient satisfaction while managing the cost of care. Promotes patient wellness through evidenced based practice, improved care outcomes, efficient utilization of health services, and appropriate level of care for patients during hospitalization and on a continuum after discharge. Provides discharge-planning education and makes referrals to inter-professional teams when necessary. Initiates links with post-acute external care resources. Anticipates and/or identifies patient educational needs, discharge planning issues and effectively collaborates to expedite early discharge planning. Acts as an advocate for the patient, functioning in various care settings and across the continuum of care; achieving desired outcomes for both the clients and healthcare agencies.
    Responsible for utilizing the nursing process (assessment, diagnosis, outcomes/planning, implementation and evaluation) to provide individualized nursing care to patients. Collaborates with other inter-professional colleagues, including physicians, to plan, implement and evaluate care. Demonstrates competency and practices within the full scope of nursing expertise/knowledge and utilizes appropriate age and population specific standards as designated in their assigned clinical setting. Cares for patients in all phases of preventative care, health maintenance, diagnosis, treatment, and follow-up as patients move along the continuum of care. Responsible for the planning and coordination of care, patient assessment, patient, caregivers, and family education, triage, and various other nursing interventions. Functions within the scope and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure. The Sanford Professional Nursing Practice recognizes the Scope and Standards of Practice and the Code of Ethics for Nurses with Interpretive Statements as published by the American Nurses Association as the foundation of nursing care delivery and professional conduct.
    
    Qualifications
    
    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 CNEA). Bachelor s degree in nursing required, or in the process of acquiring degree, and a completion date within five years upon date of hire into position.
    
    Minimum of three years of clinical nursing experience required.
    
    Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Incumbent must obtain and subsequently maintain required department specific competencies and certifications including Basic Life Support (BLS) within 60 days of hire. Certification in: Case Management (CCM), or holds a certification in their patient population specialty that they serve, is encouraged when eligible.
    
    Benefits
    
    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 https://sanfordcareers.com/benefits .
    
    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 1-877-673-0854 or send an email to talent@sanfordhealth.org .
    
    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-0194123
    
    Job Function: Care Coordination
    
    Featured: No

Keywords: Sanford Health, Fargo , RN Utilization Management, Healthcare , Fargo, North Dakota