RN-Utilization Review (S)

SSM Health is a Catholic, not-for-profit, fully integrated health system dedicated to advancing innovative, sustainable, and compassionate care for patients and communities throughout the Midwest and beyond. The organization’s 40,000 team members and 13,900 providers are committed to fulfilling SSM Health’s Mission: “Through our exceptional health care services, we reveal the healing presence of God.” With care delivery sites in Illinois, Missouri, Oklahoma and Wisconsin, SSM Health includes hospitals, physician offices, outpatient and virtual care services, comprehensive home care and hospice services, a fully transparent pharmacy benefit company, a health insurance company and an accountable care organization. It is one of the largest employers in every community it serves. For more information, visit ssmhealth.com

It's more than a career, it's a calling MO-REMOTE Worker Type: Regular Job Highlights: Eligible candidates must reside within SSM Health's four state footprint - including Missouri, Illinois, Wisconsin or Oklahoma only. Job Summary: Evaluates the medical necessity and appropriateness of hospital admissions and surgical procedures. Ensures payors receive clinical information to support services provided by hospital. Ensures hospital receives authorization from payor.

Discusses with payor regarding criteria and payor decision. Escalates denials to physician (advisor, attending consultant, outside consultant) for peer to peer consideration. Documents outcome in electronic medical record. Participates with other members of team regarding opportunities for improvement in standard work. Performs review of pre-admission, perioperative, and post operative surgical cases. Performs other utilization management tasks as assigned. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service. Performs other duties as assigned.