As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission. EO/AA

This position is responsible to work with the acutely admitted Traditional Medicare, Medicare Advantage, Commercial, Federal, State and unfunded patients. It utilizes skills and knowledge as a subject matter expert to guide case management and facility staff to improve patient care within these populations and to decrease hospital financial risk. It educates organizational employees on practices relevant to these populations. This position may be required to access and administer medications within their scope of practice and according to state law.

Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

• Daily identification and proactive co-management of organization's high risk cases such as those with an increased LOS, high dollar and frequent utilizers.
• Collaborate with unit case manager, utilization review nurse and other organization staff on establishing an appropriate plan to support case management departmental goals.
• Internal resources include but not limited to: case management medical director, nursing staff, social services, compliance, risk management, quality, physicians, financial advocates, NOVA Team and billing.
• External resources include but not limited to: CMS, Medicaid, QIO, RAC, Noridian and continuum of care providers.
• Provides guidance to utilization review staff and providers on admission status, continued stay review appropriateness and associated status changes as appropriate including but not limited to Condition Code 44. Utilizes IQ Criteria, CMS & Medicaid Guidelines and nursing judgment as subject matter expert for these populations.
• Reviews ER Only Medical Denials; pursues hearings as appropriate. Performs UT Medicaid retro authorizations & acts as resource for staff related to Medicaid.
• Reviews claims for present on admission and hospital acquired conditions; designates charges related to specific condition.
• Participates in organization Utilization Review Committee, weekly Medicare IPPS Case Reviews & RAC Audit Case Reviews.
• Evaluates reports and events to identify trends within populations and works with manager to formulate individual resolutions as well as at an aggregate level.
• Uninsured/under-insured patients' financial management including; negotiation, establishment and maintenance of post-acute care single case agreements.
• Maintain and share knowledge of Medicare & Medicaid rules and regulations; provides department education updates monthly and/or as needed.
• Performs case reviews for provider liable billing.
• Assists manager with operational implementations as appropriate.
• Facilitates case conferences as appropriate.

Knowledge / Skills / Abilities

• Ability to perform the essential functions of the job as outlined above.

• Working knowledge of PowerChart, EPIC, Microsoft Office and others as needed.

• Demonstrated key collaborator by utilization of critical thinking, written and verbal communication.

• Demonstrated ability to work autonomously and as a team member.

Qualifications

Required

• Five years Utilization Review or Case Management experience.

Licenses Required

• Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah. Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah.

Preferred

• Case Management/Utilization Review Certification designation.
• Proficiency in application of InterQual Criteria, DRG's and CPT Codes, payment methodologies.
• Basic Life Support Health Care Provider Card.

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position in a office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.