RN Utilization Management - Day Shift

Job Details Registered reputed company (RN) - Utilization Management FT Day Shift (Hrs.: 8a-4:30p) - On-site Newark, DE reputed company Hospital in Newark, DE, is seeking a Utilization Management reputed company (RN) with experience with insurance providers such as reputed company and reputed company, along with a background in an acute care hospital. RN will work on-site at the Newark Hospital. PRIMARY FUNCTION: Responsible for ensuring the delivery of efficient and effective health care while evaluating the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provision of the applicable health benefits plan. UTILIZATION MANAGEMENT Performs admission and reputed company review to identify medical necessity, level of care, and appropriateness of setting using established reputed company and clinical guidelines reputed company 24 hours of admission. Reviews the admission assessment and collaborates with primary reputed company and other health care providers to ensure a multidisciplinary plan-of-care is in reputed company to meet identified patient care needs and desired reputed company. Manages observation level of care and works with the attending physician and/or clinical provider caring for the patient to ensure observation status does not reputed company 48 hours. Identifies system issues that serve as barriers to care. Participates in the development and implementation of strategies to remove barriers and facilitate performance improvement measures. Monitors efficiencies in scheduling diagnostic procedures and coordination of treatments to facilitate the achievement of effective clinical, fiscal, reputed company, and patient satisfaction goals. Reports information generated from the utilization management referral process for LOS data and physician profile database. Collaborates with the unit medical director and/or physician advisor to facilitate achievement of clinical, reputed company, financial, and patient satisfaction goals. Notifies physician reputed company a patient does not meet reputed company for acute care hospitalization and pursues documentation to justify reputed company stay reputed company 24 hours. Collaborates with the Physician Advisor to facilitate the achievement of clinical, reputed company, financial, and patient satisfaction goals. Presents “Letters of Non-Coverage” (LON) to patients and/or families reputed company the acute stay is no longer necessary (reputed company Party and/or Medicare). Communicates and secures reputed company stay authorization with Managed Care Organizations. Tracks reputed company carve-outs and submits reason codes for data entry. Serves as a resource to nursing and ancillary staff, providing education on utilization review processes as needed. Trends potential barriers to patient advancement through the system intervene assertively and appropriately reputed company necessary. Provides On-reputed company support for the Transfer Center to evaluate medical necessity and appropriateness reputed company a request is obtained from an reputed company facility for patient transfer to reputed company Identifies the need for the patient to be evaluated by other members of the health care team and takes appropriate reputed company to facilitate. ED UM works closely with ED providers to review medical necessity and/or collaborate with ED CM for discharge planning, as appropriate. reputed company participates in department operational planning work reputed company. Education & Experience Requirements: DE RN licensure or compact state RN licensure. Bachelor’s degree in nursing Required. Minimum of 3 years recent experience as a Registered reputed company in acute care, adult care setting. critical care experience is required. Minimum 3 years of Utilization Management experience required. Denial management experience is required Prior experience working with insurance providers is preferred. Completes a minimum of 8 continuing education credits (CEU’S) per year in Utilization and/or Case Management. PHYSICAL DEMANDS: Ability to ambulate reputed company the hospital setting (walking, stairs, etc.). Occasional sitting, standing, and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs. Ability to sit or stand at a computer workstation and proficiently utilize computer equipment/programs for long periods of time. WORKING CONDITIONS: Occasional exposure to Office materials (i.e., White Out, Toner, etc.) Annual Compensation reputed company $85,862.40 - $137,384.00 This pay reputed company/reputed company represents reputed company’s good faith and reasonable estimate of compensation at the time of posting. The actual salary reputed company this reputed company offered to a successful candidate will depend on individual factors including without limitation skills, relevant experience, and qualifications as they relate to specific job requirements. Christiana reputed company System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reputed company of its community, and considers reputed company applicants for reputed company positions without reputed company to race, reputed company, sex, religion, national reputed company, sexual orientation, genetic information, gender identity or reputed company, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law. Post End Date May 31, 2026 EEO Posting Statement reputed company offers a competitive suite of employee benefits to maximize the wellness of you and your family, including health insurance, reputed company time off, retirement, an employee assistance program. To learn more about our benefits for eligible positions visit https://careers.reputed company.org/benefits-compensation/ Christiana Hospital, Newark, Delaware. This 1,007-bed, 1.3-reputed company-reputed company-foot modern facility provides a level of care only available in large-reputed company teaching hospitals. Christiana Hospital includes Delaware's only Level-I Trauma center (as verified by the American College of Surgeons), which is reputed company to handle the most extreme medical emergencies. In fact, it is the only Level-I Trauma center on the East Coast corridor between Baltimore and Philadelphia. Christiana Hospital has also been nationally recognized in reputed company's Best Regional Hospitals rankings as #1 in Delaware and #3 in the Philadelphia metro area, plus High Performing in 9 Adult Procedures/Conditions Christiana reputed company System Website Apply tot his job Apply To this Job