M Health Fairview has an immediate opening for a Utilization Management Specialist RN. This position provides comprehensive assessment, planning, coordination, implementation, and reporting of complex clinical data.
The utilization management specialist is responsible for the completion of admissions and continued stay reviews, obtaining insurance certification/authorization necessary to secure reimbursement. This position assesses the patients plan of care and progress of the patient throughout an acute care and/or outpatient episode across the Fairview system. The intensity of assessment is situational and appropriate based on payer requirements. The utilization management specialist concurrently monitors the appropriateness of admission and continued stay days using InterQual criteria and Fairview guidelines. This position identifies/resolves barriers which may hinder effective patient care.
This is a 1.0 FTE (80 hours per two week pay period), benefit-eligible position.
This position will work out of M Health Fairview's offices located at 400 Stinson Boulevard, Minneapolis, MN.
Performs utilization management in accordance with all policies, procedures, regulatory and accreditation requirements, as well as application professional standards.
Evaluates patient progress daily via chart review and/or collaboration with care transitions specialist. Obtains necessary medical reports and subsequent treatment plan requests to conduct ongoing reviews.
Applies evidence based criteria to determine appropriateness of level of care, length of stay, and discharge planning.
Collaborates with physician advisor and/or primary physician on all cases related to level of care and status.
Documents review information in chart, as appropriate.
Acts as financial steward by optimizing the patients medical benefits, as well as optimizing reimbursement.
Ensure Medicare guidelines are followed including facilitation of appeals related to medical necessity or appropriateness.
Analyzes patient records and participates in interdisciplinary collaboration with health care team.
Collaborates with health care team partners, including care transition specialists, care coordinators, physicians, clinicians, payers, non-clinical staff, HIMs, central business office, admissions, patient placement and clinical managers on level of care, identified barriers, reimbursement issues, and other issues related to utilization management activities.
Understands and follows system and facility UM plans.
Works with compliance to ensure documentation meets regulatory requirements.
Participates in interdisciplinary communication related to utilization review issues.
Educates on status. Provides all customers with excellent service experience.
Bachelors degree in Nursing (BSN) or currently serving in the role (grandfather status)
Current RN licensure in MN
3-5 years utilization review or case management experience in hospital, clinic, insurance company or long term care facility
Prior Epic EMR experience
Prior Utilization Review experience is highly preferred
Prior experience with InterQual is highly preferred
Prior patient care experience is preferred
Prior performance improvement experience is preferred
Ability to work independently, prioritize work, and excellent communication skills
Excellent computer and database management skills
Must have working knowledge of use of evidence based guidelines
Must demonstrate critical thinking skills, problem-solving ability, effective communication skills and time management skills
Must demonstrate ability to work effectively on an interdisciplinary team
Must be able to work flexible hours, including covering weekends, evenings, and on call, as assigned.
Must be willing to travel to other Fariview sites as needed.
Together with the University of Minnesota and University of Minnesota Physicians we have created M Health Fairview. M Health Fairview is the newly expanded collaboration among the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services. The healthcare system combines the best of academic and community medicine — expanding access to world-class, breakthrough care through our 10 hospitals and 60 clinics.Fairview Health Services (fairview.org) is an award-winning, nonprofit health system providing exceptional care across the full spectrum of health care services. Fairview is one of the most comprehensive and geographically accessible systems in the state, with 10 hospitals—including an academic medical center and long-term care hospital—serving the greater Twin Cities metro area.Its broad continuum also includes 60 primary care clinics, specialty clinics, senior living communities, retail and specialty pharmacies, pharmacy benefit management services, rehabilitation centers, counseling and home health care services, medical transportation, an integrated provider network and health insurer PreferredOne. In partnership with the University of Minnesota, ...Fairview’s 32,000 employees and 2,400 affiliated providers embrace innovation to drive a healthier future through healing, discovery and education.