RN - (Utilization Management Review Specialist - FT | Days | 80hrs-2weeks)
Catholic Health Initiatives - Lincoln, NE

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Serves as the information coordinator and educator for the hospital wide Utilization Management program. Reviews medical necessity for scheduled admissions, length of stay, and promptness of service. Retroactively reviews appropriateness of continued stays, implementation of effective discharge planning, assuring Nebraska Heart Hospital’s scope of service meets the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Works collaboratively with Clinical, Quality, Compliance, and Financial services to assure that information is being channeled to the appropriate committees/teams.

1.Develops and implements the utilization management plan in accordance with the mission and strategic goals of the organization; federal and state laws and regulations, and accreditation standards.

2.Develops and implements systems, policies and procedures for prospective, concurrent and retrospective case review, clinical practice guidelines, care maps, clinical protocols and reporting quality of care issues identified during the utilization review process.

3.Understands and interprets medical necessity for hospital admission and continuation of inpatient stay for commercial insurance payers, third party administrators and managed care organizations and the centers for Medicare and Medicaid Services.

4.Educates and trains management, staff and business associates as to the utilization management plan and their respective responsibilities relative to the plan.

5.Collects, analyzes and maintains data on the utilization of medical services and resources.

6.Prepares and presents utilization management summaries to management identifying potential areas for improvement, quarterly or as requested.

7.Reports quality of care issues identified during the utilization review process according to the policy and procedure.

8.Works with insurance companies to obtain prior authorizations and referrals from insurance companies for patients who are scheduled for appointments, diagnostic procedures, or surgeries as needed for same day admissions.

9.Responsible for working directly with patients, family members, area hospital staff, physicians and other community agencies in obtaining referrals and providing case management for patients of Nebraska Heart. This includes screening, pre-certification, pre admission and admission process; care plan management and coordination; ensuring medical necessity through monitoring severity of illness and intensity of services; and evaluation of services to ensure patient needs are appropriately met.

10.Coordinates with other organizational departments and outside facilities/agencies to facilitate a smooth admission to Nebraska Heart.

11.Evaluates admission and continued stay criteria guided by available and appropriate resources (i.e. Medicare, PRO). Implements strategies and communication to ensure appropriate utilization.

12.Serves as an advocate and liaison between patient/family and physicians and team members.

13.Obtains third party payor admission pre-authorization as needed. Assures that complete and accurate payment arrangements are in place upon admission and that payment information is completely and accurately documented on the system upon admission.

14.Responsible for ensuring all billing information is complete and accurate prior to patient discharge so that clean bills can be generated and payment can be received without inordinate interaction and correction by other staff

15.Assists with the development, assessment, implementation, and monitoring of a comprehensive plan of care for patients meeting our high risk screening criteria by coordinating an interdisciplinary team approach to service and resource delivery beginning on a preadmission basis and follows through placement into follow up after care in collaboration with the hospital team.

16.Consistently evaluates the appropriateness of levels of care, diagnostic testing, and clinical procedures, quality and clinical risk issues.

17. Maintains a knowledge base of the most current prior authorization and referral requirements for insurance companies. Knowledge base is kept up by reading newsletters, accessing insurance company websites, and attending meetings and workshops.

18.Answers patient, staff, and physician inquiries regarding the status of prior authorizations and referrals.

19.Acts as a resource to physicians, managers, and staff regarding prior authorization policies and procedures and maintains proper reference materials for staff to utilize.

20.Researches and investigates claims that have been rejected or denied. Works with coders to correct and resubmit claims.

21.Demonstrates effective and professional communication skills, both oral and written.

22.Works with and reports problems to physicians and management to solve inter and intra-department issues, keep open lines of communication, and increase departmental efficiency.

23.Assists in creating and maintaining department budget and reports. Coordinates and creates proposals for assigned projects.

24.Participates as a team member and providesleadership to colleagues, students and other team members to ensure that workloads are distributed fair and equal and that our number one goal of providing excellenceof service and care to our patients and their families is accomplished everyday.

25.Consistently and reliably works scheduled hours.

26.Maintains strict confidentiality of patient and families.

27.Willingly shares and promotes expertise and teamwork with fellow members and assists in the orientation of new staff.

28.Consistently seeks ways to improve work procedures and methods to increase effectiveness and efficiency in the organization.

29.Committed to conducting all behavior with integrity and high ethical standards.

30.Communicates with patients, families and team members in a manner which promotes dignity and eespect.

31.Performs other duties as may be assigned by management.


Knowledge, Skills, & Abilities


1.Knowledge of general office practices and procedures.

2.Knowledge of medical terminology, coding and medical records.

3.Knowledge of rules and regulations as they pertain to the area of responsibility.

4.Knowledge of grammar, spelling and punctuation of the English language.

5.Skill in operating a personal computer and various software packages including the Microsoft Office Suite.

6.Skill in operating office equipment such as copier, fax, telephone, calculator, etc.

7.Skill in creating and maintaining written records and reports.

8.Ability to organize, prioritize and manage multiple projects.

9.Ability to communicate effectively and positively with staff members.

10.Ability to work independently, with little or no supervision.

11.Ability to maintain the strictest of confidentiality.

12.Ability to relate to staff and various outside contacts in a courteous and professional manner.

13.Ability to communicate clearly and concisely.

14.Ability to apply common sense understanding to carry out written and/or oral instruction.

15.Ability to communicate effectively with patients of all ages.

16.Ability to read, understand and follow oral and/or written instruction

17.Ability to examine documents for accuracy and completeness.

Completion of a Registered Nurse program at an accredited institution and current state RN licensure required. One to two years experience in utilization management or related field is preferred. Cardiac experience also preferred.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work requires


Prolonged sitting.

Occasional walking, stooping, bending, and stretching for files and supplies.

Occasionally lifting of files and supplies weighing up to 10 pounds.

Requires manual dexterity sufficient to operate a keyboard, telephone, fax machine, copier and other office equipment as necessary.

Vision must be correctable to 20/20 and hearing must be within normal range for telephone contacts.

It is necessary to view computer screens and type for long periods of time.

Normal office environment.

Additional Responsibilities


Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times

Adheres to and exhibits our core values:

: Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.


: Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.


: Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.


: Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.

Maintains confidentiality and protects sensitive data at all times

Adheres to organizational and department specific safety standards and guidelines

Works collaboratively and supports efforts of team members

Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community

Catholic Health Initiatives and its organizations are Equal Opportunity Employers. /CB


Medical/Surgical Services

Primary Location

NE-Lincoln-Nebraska Heart Hospital



Scheduled Hours per 2-week Pay Period


Weekends Required



Full Time

Catholic Health Initiatives - 17 months ago - save job - block
About this company
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For Catholic Health Initiatives (CHI), returning sick people to good health is more than a business -- it's a mission. Formed in 1996...