Skip to main content
a group of women wearing face masks

Utilization Management Nurse - RN

Description

HOW WE CARE FOR YOU:

At Rochester Regional Health, we are dedicated to getting healthcare right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for your career while caring for the community.

  • Health & Wellness Benefits starting Your First Day
  • Personal Time that includes Vacation Time, Sick Time & Holidays
  • Retirement Savings Program
  • Same Day Pay through DailyPay
  • Student Loan Repayment Program
  • Tuition Assistance & Reimbursement
  • Free Parking

SUMMARY:

The Utilization Management Nurse will review all inpatient medical necessity denials for the health system based on InterQual and/or CMS guidelines.

STATUS: Full Time

LOCATION: Rochester General Hospital

DEPARTMENT: Utilization Management

SCHEDULE: Monday - Friday; Days. No weekends or holidays.

ATTRIBUTES:

  • 3 years of acute hospital care, Case Management and/or Utilization Management experience
  • Current New York State Registered Nurse License
  • Excellent oral and written communication and interpersonal skills
  • Good understanding of medical management techniques and processes
  • Strong organizational and problem solving skills
  • Electronic Medical Record experience (Epic)

RESPONSIBILITIES:

  • Patient Claims. Review standard UM sources for potential inpatient medical necessity denials. Review patient class in the event manager, assist with LOC determination retrospectively, and changes patient class as it relates to the Provider order for billing purposes.
  • Insurance Review. Prepare the UM review findings, initiate and 1st, 2nd, and/or arbitration appeals as needed. Document in all areas that an appeal has been initiated or no appeal is necessary per UM reviews. Track and monitor all denials, appeals, arbitration responses to payers/audits.
  • Compliance. Maintains accountability to hospital, state, and federal regulations, and professional standards. Initiates alternate level of care determinations in compliance with regulatory and contractual agreements.

PHYSICAL REQUIREMENTS: M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

LICENSES/CERTIFICATIONS:

  • BLS - Basic Life Support - American Heart Association (AHA)
  • RN - Registered Nurse - New York State Education Department (NYSED)

PAY RANGE: $76,500.00 - $105,000.00

The listed base pay range is a good faith representation of current potential base pay for successful applicants. It may be modified in the future. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran
Blue 2

Explore our job opportunities

View jobs