Job Description
The University of Iowa Healthcare Downtown Campus, Utilization Review team is looking for a Nurse Clinician to functions as a clinical nurse expert and clinical coordinator acting as nurse liaison to physicians, patients and administration. Candidate will clinically review and facilitate changes in level of care, based on systematic evaluation, utilization management and evidence-based research. Incorporating Milliman care Guidelines in each review. This position will strive to achieve quantitative measures of success across the UIHC Hospitals, including Stead Family Hospital and University of Iowa Healthcare.
Position Responsibilities - Perform a variety of admission, concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
- Utilize an evidenced-based clinical review screening criteria as a guide to support medical necessity determinations and refers cases with failed criteria to the Physician Advisor or appeal as necessary in accordance with the UM plan.
- Collaborate with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seek additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
- Validate commercial payer authorization within the contractual time frame at time of presentation, every third day or as needed (e.g., ED, Direct Admit, Transfers). - --Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary.
- Participate in the resolution of retrospective reimbursement issues, including appeals, third-party payer certification, and denied cases.
- Provide clinical information to relevant clinical team members regarding patient needs and/or newly identified issues, specifically working with the Utilization Management team.
- Serve as clinical resource to social services and other providers/nurse navigators, specifically regarding the compliance portion of the level of care.
- Review data specific to utilization management functions and reports as requested.
- Monitor effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, supporting the evaluation of the data, reporting results to various audiences, and implementing process improvement projects as needed.
- Participate in analyzing, updating, and modifying procedures and processes to continually improve utilization review operations.
- Work collaboratively with Nurse Navigators and Social Workers to expedite patient discharge.
- Participate in Care Coordination Division - Utilization Management initiatives or other projects according to departmental and organizational monitors.
- Perform basic administrative tasks related to the job as required by the Care Coordination Division to maintain accurate records and to ensure worker accountability/productivity.
- Maintain a highly acceptable level of professional conduct and respect for medical staff, coworkers, and hospital staff to foster a desirable image for the institution.
- Denote relevant clinical information to proactively communicate to payers for authorizations for treatments, procedures, and Length of Stay – send clinical information as required by the payer.
- Maintain current knowledge and understanding of hospital utilization review processes third party coverage with respect to Medicare, Commercial and Medicaid policies and procedures.
- Maintain compliance with all hospital/departmental policies/procedures assigned by the department manager, including work hours, scheduling, and other criteria for the expected daily operations of the department. Comply with the Code of Ethics and Guide for Professional Conduct.
- Welcome the richness of talent from a diverse workforce.
- Maintain strict confidentiality in dealing with all patient-related activities and other sensitive physician and/or hospital issues by strictly adhering to hospital confidentiality of information policies.
- Facilitate open communication and good working relationships with Bed Management and/or Transfer Center to promote and enhance efficient operations within the Care Coordination Division.
- Acknowledge budgetary constraints in department operations and strives to perform duties cost-effectively and efficiently.
- Demonstrate ability to prioritize multiple work assignments to accomplish the assigned workload.
- Assist in the orientation and precepting of professional staff and colleagues as assigned.
- Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications, establishing personal networks; participating in professional societies.
- Comply with federal, state, and local legal and certification requirements by studying existing and new legislation, anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.
- Perform other duties as may be assigned to ensure that departmental objectives are fulfilled.
Percent of Time : 60%
Schedule : Monday – Friday, shifts primarily between 7:00 am and 6:00 pm. Occasional holiday rotation.
Pay Grade: Benefits Highlights - Regular salaried position located in Iowa City, Iowa
- Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans
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Qualifications - External Required Qualifications - A Baccalaureate degree in Nursing is required.
- Current license to practice nursing in Iowa is required by date of hire.
- 1-3 years of recent clinical health care experience including care coordination
- Demonstrated experience coordinating care along the healthcare continuum
- Proficiency in computer applications including Microsoft Excel, Word, and PowerPoint
- Demonstrated excellence in critical thinking, organizational skills, independent decision-making, time management, prioritization, and problem-solving skills
- Excellent written and verbal communication skills
- Experience working in an interdisciplinary team.
Desired Qualifications - Experience with care coordination for patients across the spectrum of different specialties.
- Demonstrated expertise spanning pediatric, adult, and geriatric care.
- Ability to work independently as well as within a team.
- Demonstrated experience in providing education to multiple stakeholders.
- Excellent written and verbal communication and interpersonal skills are required.
- Experience working with case management; utilization management; insurance contracts or knowledge of CPT and ICD-9/10 codes or clinical guideline systems such as Milliman© InterQual© or other similar system.
- Certification in a role or specialty through a nationally recognized professional nursing certification body is desired.
- Experience and knowledge with Medicare Guidelines of outpatient observation and 2 midnight rule is desired.
Position And Application Details In order to be considered for an interview, applicants must upload the following documents and mark them as a “Relevant File” to the submission:
Job openings are posted for a minimum of 14 calendar days and may be removed from posting and filled any time after the original posting period has ended.
Successful candidates will be required to self disclose any conviction history and will be subject to a criminal background check and credential/education verification. Up to 5 professional references will be requested at a later step in the recruitment process.
For additional questions, please contact seton-vinsand@uiowa.edu
Additional Information
- Classification Title: Nurse Clinician
- Appointment Type: SEIU
- Schedule: Full-time
Compensation Contact Information
- Organization: Healthcare
- Contact Name: Seton Vinsand
- Contact Email: seton-vinsand@uiowa.edu
Job Tags
Holiday work, Full time, Local area, Shift work, Night shift, Monday to Friday,