Utilization Management Specialist

This is a fully remote position, open to applicants in Montana.

📋 Description

• Review all daily inpatient and observation admissions within the Logan Health system.

• Assess physician documentation and patient information to ascertain suitable admission status.

• Continuously reassess patients during their stay to confirm ongoing criteria for their level of care.

• Collaborate with the physician UM Advisor, case management team, and insurance partners to facilitate authorizations and reviews of medical necessity.

• Assist in scheduling and coordinating peer-to-peer physician evaluations.

• Communicate effectively with providers, nurses, and other stakeholders to ensure precise documentation and seamless transitions of care.

• Identify and resolve issues that may cause delays in reviews or impact compliance.

• Utilize electronic medical records for documentation, review, and reporting purposes.

• Coordinate and ensure accurate identification of patient status using validated criteria.

• Complete reviews of short stay work queues and monitor and trend results for reporting and educational purposes.

• Recognize opportunities for process and system improvements and lead performance initiatives.

• Identify and address system process issues, delays, and obstacles impacting utilization management.

• Respond to clinical inquiries concerning medical necessity and patient status.

• Conduct concurrent and retrospective reviews.

• Aid in the preparation of insurance denial appeal letters, audit activities, and payer inquiries.

• Resolve utilization management and patient status concerns with relevant stakeholders.

• Consult with appropriate disciplines and departments to expedite care and ensure accurate documentation.

• Refer utilization management issues to leadership or relevant stakeholders and oversee their resolution.

• Engage in the development, implementation, teaching, evaluation, and revision of departmental utilization management standards.

• Participate in the onboarding of new departmental staff.

• Document concerns related to utilization management, quality, and risk, and refer them for follow-up.

• Work autonomously while collaborating with the interdisciplinary team.

⛳️ Requirements

• Current Montana RN License or a multi-state compact license with authorization to practice nursing in Montana.

• Bachelor’s degree in Social Work.

• Associate’s degree required; Bachelor’s degree preferred.

• A minimum of five (5) years of experience in an acute care hospital setting is required.

• CCM Certification is preferred.

• Previous experience as an inpatient utilization review nurse or UM specialist is preferred.

• Knowledge of Medicare and Medicaid UM regulations, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management is preferred.

• Exceptional interpersonal skills with the capability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.

• Strong verbal and written communication skills, including the ability to effectively communicate with diverse audiences.

• High level of computer literacy.

• Strong analytical thinking skills.

• Experience in acute care (hospital) settings.

• Must currently reside in the State of Montana.

• Must successfully pass pre-employment criminal background, reference, drug, health and immunizations, and physical demand screenings.

🏝️ Benefits

• Four-day work week.

• Affordable Medical Benefits package.

• 401(k) with a generous immediate employer match.

• Discount on Logan Health Fitness Center Membership!

• A supportive, mission-driven nursing culture that emphasizes quality, compassion, and person-centered care!