Role: On-site Hospital Utilization Management (UM) Nurse, responsible for optimizing patient care and hospital resources through real-time clinical and administrative collaboration.
Responsibilities:
- Perform admission and concurrent medical record reviews to assess patient classification and medical necessity using established criteria.
- Meet with physicians and interdisciplinary teams to discuss documentation gaps and support appropriate care levels.
- Participate in bedside rounds and departmental huddles to provide immediate input on care progression and necessity.
- Manage emergency department admissions by providing recommendations on the most suitable level of care.
- Ensure compliance with payer regulations by issuing necessary notices and minimizing avoidable hospital days to prevent financial loss.
- Maintain accurate documentation of clinical reviews, insurance details, and post-discharge accounts.
- Support continuous performance improvement and professional development, mentoring others as needed.
Qualifications & Skills:
- Registered Nurse (RN) license (single or multi-state Compact) required; BLS certification within 90 days.
- Minimum of 3 years of clinical experience with strong knowledge of case management processes.
- Excellent verbal and written communication skills, organizational skills, and ability to build relationships with physicians and teams.
- Proficiency in screening criteria, clinical data review, and critical thinking to influence hospital throughput.
- Strong computer skills and adherence to policies and standards.