Utilization Management Nurse - Behavioral Health & Wellness Center

Overview

Utilization Management Nurse - Behavioral Health & Wellness Center

Schedule: Mon-Fri 8:00 - 4:30

At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Children’s is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

Responsibilities

• Reviews the appropriateness of all observation and inpatient admissions using approved inpatient care criteria; notifies admitting physician and NCM of admissions not meeting acute care guidelines; collaborates with NCM physician advisor; guides admitting physicians in physician-to-physician reviews with third-party payers; documents communications in EPIC.
• Ensures appropriate utilization of observation and inpatient status from admission to discharge; monitors patients and, with physicians, performs status conversions; documents discharges; notifies interdisciplinary team of status changes; ensures assigned length of stay is appropriate; provides concurrent and retrospective reviews to secure inpatient coverage.
• Maintains electronic documentation for all UM activities; communicates impacts to the patient’s plan of care; manages inpatient denials due to lack of medical necessity; documents potential denials and non-covered days; tracks denials.
• Participates in revenue-cycle activities; collaborates with NCMs to identify, document, and trend Avoidable Days; works to optimize reimbursement and minimize extended LOS; responds to trends from recovery audits.

Qualifications

Education

• Education: Bachelor's Degree from an accredited college or university in nursing or equivalent work experience (Required)

Experience

• Experience: Minimum 5 years in nursing, preferably in a pediatric setting (Required)

Skills and Abilities

• Skills and Abilities: Knowledge of healthcare resource management principles; clinical pathways and trajectories of pediatric diagnoses; payor requirements; strong communication with interdisciplinary teams; critical thinking; interpersonal skills; negotiation and problem solving in utilization management; adaptability and creativity.

Licenses and Certifications

• Licenses and Certifications: RN - Registered Nurse state licensure (or compact licensure) Required
• Licenses and Certifications: RN-BC - Case Management Nurse Preferred

Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Health Care Provider
• Industries: Hospitals and Health Care