The Broadlawns Medical Center campus includes an acute care hospital, primary and specialty care clinics, urgent care and emergency services, lab, radiology, dentistry, inpatient and outpatient mental health, crisis team, and community-based behavioral support services. Broadlawns accepts all forms of insurance and its approach to healthcare and quality outcomes earned a Level 3 rating from the National Committee for Quality Assurance, the highest achievable status for a medical delivery model.We are a safety net hospital and our Patients are our North Star! With a dedicated staff of over 160 physicians and 1,600 employees, Broadlawns Medical Center ensures that our community has access to high quality healthcare that is coordinated, compassionate and cost-effective. We provide our employees a top-rated benefits package, supportive work culture, and more!
GENERAL DESCRIPTIONThis position is responsible to the UM Supervisor. The position assures quality patient care and effective utilization of BMC resources through the implementation of the Utilization Management (UM) Plan. The Nurse Reviewer provides utilization management, including initial, concurrent and retrospective reviews. This position assists and supports providers with managed care denials as a liaison to insurance requirements. Assistance with appeals will also be required.
CHARACTERISTIC DUTIESRuns daily report of all admissions to review and obtain authorization when required. Uses standardized criteria to screen admissions and continued care decisions for medical necessity and appropriateness and confirms diagnoses, co-morbidities and DRGs based on standard, accepted criteria. Provides admission, continued stay, discharge, and retrospective reviews. Obtains certification on all patients requiring third party payer review. Maintains knowledge of managed care companies and their requirements for clinical management. Negotiates directly with managed care companies to assure appropriate resources are available for patients. Assists physicians in appealing denials of admission or continued stay decisions. Interacts with other BMC departments to perform UM duties. Collects data on UM activities and provides reports for the supervisor, administration and medical staff. Tracks problem cases identified and establishes corrective actions in relations to all aspects of a patient's care (clinical, financial, insurance). Maintains contact with appropriate departments for follow up on these cases. Implements corrective actions based on the results of monitoring and reporting. Communicates with all levels of hospital personnel and outside vendors to assure positive working relationships. Acts as a patient advocate to assist with questions, concerns, complaints or requests. Report concerns to supervisor or respective Department Directors to coordinate any needed corrective action. Attends staffing/discharge planning meetings and various educational offerings. Learns and uses the BMC electronic medical record to attain a proficient level. Uses standardized Clinical Level of Care Criteria and becomes proficient in application. Delivers cost information to patients and guardians as identified. Performs other job-related duties as assigned. Provides service excellence in all activities. Participates in orientation process for department staff. Provides resident physician education as needed.
PERFORMANCE STANDARDSDemonstrates awareness and application of all policies. Demonstrates self-responsibility and accountability for their professional practice. Demonstrates mid directed teaming skills and ability, participates in continuing education to further their professional development. Demonstrates flexibility to adapt to changes in workload, schedule, department function and procedures. Actively participates in creating a positive work environment by demonstrating teamwork and cooperative, responsive behavior. Demonstrates effective communication methods and skills, using lines of authority appropriately. Meets or exceeds competency criteria specific to the tasks and duties of the position. Demonstrates service excellence in all activities and interactions. Review all admissions assigned within 18 hours of admission for acuity and appropriate level of care. Review continued stay Observation patients for appropriate level of care every 24 hours. Other continued stay reviews completed at least every 72 hours for non-managed care patients. Review all managed care patients per insurance company's request. Peer to peer reviews conducted as outlined in the Utilization Management policy. Eligible for Remote/Hybrid Work policy after minimum of six months of employment. Must be able to demonstrate ability to work independently and meet all required performance metrics.
MINIMUM QUALIFICATIONSCurrent RN License, bachelor's degree in a human service field or master's degree in a human service area. Minimum of two (2) years of health care experience with hospital setting preferred. Experience with medical or other managed care/insurance reviews.
PREFERRED QUALIFICATIONSExperience working for managed care or insurance company conducting reviews. Experience applying standardized industry criteria in level of care or retrospective reviews. Prior hospital Utilization Management experience. Working knowledge of Medicare/CMS guidelines pertinent to hospital Utilization Management.
Work ShiftBenefits (FT/PT) - Retirement - IPERS
- Education Assistance
- Employee Health & Wellness
- PTO
- Free Parking
- Health Insurance
- Supplemental Insurance
- 529 College Savings Plan
- And more!
Broadlawns Medical Center is an Equal Opportunity Employer