Per Diem Utilization Management RN - National Remote

Opportunities at Northern Light Health, in strategic partnership with Optum. Whether you are looking for a role in a clinical setting or supporting those who provide care, we have opportunities for you to make a difference in the lives of those we serve. As a statewide health care system in Maine, we work to personalize and streamline health care for our communities. If the place for you is at a large medical center, a rural community practice or home care, you will find it here. Join our compassionate culture, enjoy meaningful benefits and discover the meaning behind: Caring. Connecting. Growing together. 

The Utilization Management RN provides feedback as requested to enhance negotiations with payers. Assesses for accuracy in the assignment of patient class (status) to reflect congruence with clinical condition, physician intent, and utilization review outcomes with current rules and regulatory requirements. Supports the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation and support of medical necessity/level of care. Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities. Schedule: 1 weekend a month and the rest of the time as needed and 1 holiday a year; Hours of operation: 7AM-3:30PM or 8AM-4:30PM EST You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Validates authorization for all procedure / bedded patients UM pre-admission Ensuring acquisition of pre-certification authorization, urgent/emergent authorizations, continued stay authorizations and authorizations for post-acute services from third-party payers Obtains commercial payer authorization within the contractual timeframe at time of presentation, every third day or as needed Proactively reduces the risk of denials Manages concurrent cases to resolution Partners with Revenue Cycle team to support resolution of retrospective denials Conducts initial review and continued stay review every third day for Medicare Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information Confirms that orders reflect level of care, severity of illness and intensity of service utilizing Level of Care Criteria Conducts Level of Care review using electronic system and documents outcomes. Contacts payers as applicable Refers cases with failed criteria to Physician Advisor and appeals as necessary Completes stratification tool to identify simple vs complex patient population Deploys representative within Utilization Review team to handle audits (internal and external) Responsible for coordinating and conducting utilization / medical necessity reviews for all payers upon admission & concurrently throughout the inpatient admission in compliance with the NL EMMC Utilization Management Plan Ongoing collaboration with Care Manager to ensure that patient’s condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care Performs other duties as assigned or required