Utilization Management Nurse

Xsolis is an AI-driven technology company with a human-centered approach, fostering collaboration between healthcare providers and payers through real-time transparency, objective data for increased accuracy and alignment of medical necessity decisions, and more efficient outcomes. Dragonfly®, its AI-driven proprietary platform, is the first and only solution to use real-time predictive analytics to continuously assign an objective medical necessity score and assess the anticipated level of care for every patient, enabling more efficiency across the healthcare system. Xsolis is headquartered in Franklin, Tennessee.

This position will have well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions. This individual maintains current and accurate knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to UM. The UM Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.

The essential functions include, but are not limited to the following: Coordinate and facilitate correct identification of patient status.  Facilitates optimal reimbursement through accurate certification and denial processes, including complete chart documentation ensuring that the appropriate admission status is ordered.   Coordinate and integrate UM functions.  Conducts concurrent and retrospective reviews based on Xsolis AI capabilities with usage of Client approved Care Level Score decision matrixes.   Refers cases for secondary review when appropriate.   Supports the medical necessity denial and appeal process.  Collaborate with all members of the healthcare team, both internal and external.  Refers and consults with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.  Communicate with third party payers regarding patient clinical progress.  Assists the UM team in educating providers on trends found in medical necessity statuses, authorization, and communication from third-party payers.  Participate in clinical performance improvement activities to achieve set goals.  Demonstrate positive and professional written, verbal, and nonverbal communication skills.  Apply advanced critical thinking and conflict resolution skills using creative approaches.  The responsibilities listed are a general overview of the position and additional duties may be assigned.  Supervisory Responsibilities: This role does not have any direct reports and is a single contributor role.