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.
Create Your Career With Us!
Facility: Carufel Building
Location: Fargo, ND
Address: 505 7th Ave N, Fargo, ND 58102,
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00
Daily tasks for an RN Utilization Management Specialist
• Screen all hospital admissions utilizing MCG Guidelines to
determine appropriate admission level of care.
• Utilize MCG Guidelines to determine medical necessity of
• Assist Case Management and patient care team with patient
transitions by identifying patients that no longer meet acute
criteria for continued stay.
• Prospective review of planned surgical admissions to determine
appropriate level of care.
• Obtain initial and continued stay authorization for inpatient
admissions as required by various payers.
• Management of admission and continued stay medical necessity
payer denials by facilitating or initiating an appeal.
Schedule includes: Monday - Friday 8:00 AM -4:30 PM with every
5th weekend 7:00 AM - 3:30 PM and 1-2 holidays per year.
3- 5 years of medical surgical clinical experience preferred.
Potential opportunity to transition to remote work from home
after 1 year on site, if criteria for telecommuting contract are
met and approved by leadership.
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
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 CNEA).
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, sick leave and paid time off. To
review your benefit eligibility, 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
1-877-673-0854 or send an email to email@example.com .
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.
Job Function: Care Coordination
Req Number: R-61685