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. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth abound as we grow our services and spaces, including the cutting-edge Hubbard Center for Children. Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve. Children's is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

A Brief Overview

Utilization Management (UM) is a specialty area of Nursing Case Management (NCM) and is responsible for reviewing and assessing all admissions for medical necessity utilizing standardized criteria that demonstrates the appropriate intensity of service for the severity of illness. UM includes retrospective and concurrent clinical reviews with third-party payors and actively collaborates with NCM and physicians to evaluate the medical plan, length of stay, avoidable days and appropriate use of inpatient and observation status. UM is responsible for all facets of denial management due to medical necessity and works collaboratively with patient accounts, the physician advisor, and NCM in various aspects of denial management. UM will serve as a liaison for NCM and the Access Center and be responsible for communicating third-party payor process changes to the appropriate departments.

Essential Functions

Reviews the appropriateness of all observation and inpatient admissions utilizing approved inpatient care criteria guidelines. o Notifies admitting physician and NCM of all inpatient admissions not meeting acute care guidelines. o Works directly with NCM physician advisor. o Guides admitting physician in protocols for conducting physician to physician review with third-party payers. o Appropriately documents all relevant communications in EPIC.

Ensures appropriate utilization of observation and inpatient status from admission to discharge. o Monitors all patients and works with physician to perform status conversions as appropriate. o Documents all discharges and assesses appropriateness of patient status. o Notifies appropriate members of interdisciplinary team of all status changes. o Ensure assigned length of stay (LOS) is appropriate. o Provides concurrent and retrospective reviews as needed to secure coverage of all inpatient days for patients currently admitted.

Maintains electronic documentation for all UM activities. Communicates to NCM when impacts are identified to the patient’s plan of care. Responsible for all facets of inpatient denials due to lack of medical necessity. Communicates and documents all potential denials and non-covered days. Tracks denials using department process.

Participates in various aspects of the revenue-cycle. Collaborates with the NCMs to identify, document, and trend Avoidable Days. Acts proactively at any point along the inpatient episode to ensure reimbursement is optimized (throughput). Ensures that extended LOS’ are minimized. Responds to trends discovered in recovery audits.

Education Qualifications

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

Experience Qualifications

Skills and Abilities

Knowledge of the basic principles of healthcare resource management.

Knowledge of clinical pathways and trajectories of pediatric diagnosis.

Knowledge of basic rules and regulations regarding payor requirements.

Good communication skills with members of the interdisciplinary team.

Critical thinking skills.

Must demonstrate positive interpersonal relationship skills with individuals and groups in a wide variety of settings.

Skills in negotiation and problem solving with utilization management.

Should be a creative, flexible, risk taker.

Licenses and Certifications

RN - Registered Nurse - State Licensure and / or Compact State Licensure Required and

RN-BC - Case Management Nurse Preferred

Children’s is the very best for kids and the very best for your career! At Children’s, we put YOU first so together, we can improve the life of every child!

Requisition ID : 23103