Utilization Management RN Job at Thomas Jefferson University & Jefferson Health
Thomas Jefferson University & Jefferson Health Abington, PA 19001
Responsibilities
Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Performs denial and appeal activities for inpatient hospital care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.
Essential Functions
Qualifications
Education:
Bachelors Nursing, required
AND
Experience:
3 - 5 years case management experience, discharge planning or utilization management experience required.
Minimum Certifications, Registration or License Requirements:
Registered Nurse, Pennsylvania and New Jersey. Certification in InterQual criteria preferred
Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Performs denial and appeal activities for inpatient hospital care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.
Essential Functions
- Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
- Collaborates with the Physician Advisor and members of the Multidisciplinary Team to facilitate the Case Management Condition 44 process.
- Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards.
- Performs appeal process in coordination with specific third party payor format, protocols, and timelines.
Qualifications
Education:
Bachelors Nursing, required
AND
Experience:
3 - 5 years case management experience, discharge planning or utilization management experience required.
Minimum Certifications, Registration or License Requirements:
Registered Nurse, Pennsylvania and New Jersey. Certification in InterQual criteria preferred
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