Utilization Management RN
Company: North Memorial Healthcare
Location: Lake Elmo
Posted on: August 20, 2019
DescriptionThe Utilization Management RN, under the supervision of
the Utilization Management Manager, acts as a support resource to
the Medical Staff of North Memorial Health (NMH) and Maple Grove
Hospital (MGH) in relationship to clinical documentation of
admitted customers. The UM RN assess the documented medical
necessity of each bedded patient to assist the MD as needed to
determine an appropriate admission status. They provide clinically
based information to assist with care coordination and support the
delivery of quality customer care as efficiently as possible. The
UM RN has accountability for assisting in ensuring quality clinical
outcomes, and appropriate resource management related to admission,
readmission, length of stay, extended stay, avoidable days and
discharge planning. They work with the medical and care teams
(nursing, social services, therapies, and ancillary departments) to
ensure the customer is receiving the right care, at the right level
across the continuum. Additionally, they know the disease,
trajectory of illness, treatment plan, standard of care for the
diagnosis, expected outcome, and Length of Stay (LOS) for the case
type. They work with all admissions (bedded customers) excluding
any customers in the Emergency Department Finally, they UM RN
actively and consistently demonstrates the mission, vision, values
and guiding principles of North Memorial Health.
--- Works in collaboration with the physicians, physician advisor,
members of the healthcare team and payers to address all
clinical/customer/payer issues in a timely manner.
--- Conducts assessment and care planning.
--- Reviews documentation and completes an initial Inpatient screen
to all customers for admission (Inpatient-IP,
OBSERVATION/Outpatient-OBS, OPIAB/OP) appropriateness, uses system
approved criteria (InterQual-IQ or Milliman Care Guidelines-MCG) to
identify needs related to clinical outcomes, complex care
coordination, and transition/discharge planning.
--- Documents approved/appropriate status in EPIC- as communication
mechanism to Case Managers/Social Workers for ongoing care
--- If a case fails the screening criteria, contacts the physician
to review the documentation, requests further
information/documentation to assure appropriate status is achieved
--- Refers cases to UM Physician Advisor when documentation does
not support the status (specific screening) at time of
--- Communicates outcomes of UM Physician Advisor process to
appropriate physician and documents in EPIC outcome.
--- Reviews Observation cases daily to assess possible need for
conversion in status.
--- Reviews Inpatient cases as requested by payors/LOS parameters
for discharge indications.
--- Screens cases from an ongoing perspective as requested by
--- When a clinical status changes, applies appropriate Condition
Code (CC44- inpatient(IP) converted to OP/OBS or Occurrence Span
code (OSC 72) OBS converted to IP) and documents in EPIC-claim info
screen as well as note in customer progress notes.
--- Communicates with Case Management/Social Services for status
revision (may affect placement/coverage/customer satisfaction) so
appropriate IMM/MOON may be issued.
--- Documents status changes and how status change determinations
were made in EPIC-Authorization/Certification Information account
--- Reviews EPIC Master Daily Schedule to assess for
appropriateness of proposed surgical procedures.
--- Reviews readmission chart to determine possible premature
--- Reviews discharge chart to determine case/status
--- Reviews extended stay chart to assess for Medicare 20-day
recertification documentation (medical necessity/ongoing
--- Provides clinical information to reflect that customers are
placed in the appropriate level of care.
--- Addresses any issues related to status and clinical
appropriateness on a concurrent and retrospective basis.
--- Maintains awareness of relevant payor requirements,
restrictions and reimbursement methods.
--- Communicates reimbursement information to physicians/social
workers/customers and families as appropriate.
--- Assists in the identification and communication of any issues
related to infection control, risk management, quality of care, and
customer medical management, by reporting variance cases to
appropriate departments for follow up.
--- Adheres to the organizational policies and standards as well as
standards from external regulatory agencies and accrediting bodies
(i.e., JCAHO, CMS, Department of Public Health, etc.).
--- Serves as a reference and resource for business office, medical
records, compliance, partnering clinics and health care
--- Associate's Degree in Nursing and 3-5 years of Utilization
Management/Review experience required.
--- Bachelor's Degree from an accredited school of nursing
--- Three (3) to five years of previous acute care nursing
--- One (1) year of direct utilization management, utilization
review or case management experience required.
--- Hospital utilization management, utilization review or case
management experience required.
Knowledge, Skills and Abilities
--- Knowledge of nursing theory and practice and primary care
principles and practices.
--- Knowledge of Medicare rules and regulations.
--- Knowledge of current case management principles, utilization
management, length of stay management, and/or transition/discharge
--- Knowledge of current nursing principles, techniques and
--- Demonstrated ability to deal with conflict in a positive
manner. Has an awareness of, responds to, and considers the needs,
feelings and capabilities of others.
--- Strong communication skills with demonstrated ability to
express ideas and information clearly and concisely in a manner
appropriate to the audience.License Requirement--- Current
licensure and registration as an RN in the State of MN.
Keywords: North Memorial Healthcare, Blaine , Utilization Management RN, Executive , Lake Elmo, Minnesota
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