Per Diem Utilization Management Nurse RN

Opportunities At Northern Light Health

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 Nurse 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: Flexible as it is per diem - must be able to work 7 AM - 3:30 AM or 8 AM - 4:30 PM EST - Rotating holidays and weekends - available two shifts per week

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Validates authorization for all procedures/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 the 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 the 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

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Associate's Degree (or higher) in Nursing
• Current and unrestricted RN Compact State licensure OR unrestricted RN license in state of residence and Maine
• 3+ years of acute clinical practice or related healthcare experience
• 1+ years of Utilization Management RN experience
• 1+ years of experience working with Cerner
• 1+ years of experience working with InterQual
• 1+ years of experience working with insurance and denials

Preferred Qualifications:

• Bachelor's Degree in Nursing (BSN) (or higher)
• ACM, CCM or other certification applicable to utilization management within 3 years of hire
• Experience in utilization review and concurrent review

Soft Skill:

• Strong communication and interpersonal skills including ability to work collaboratively and cooperatively within a team including internal and external customers
• Strong organizational skills and ability to set priorities

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.