RN, Utilization Management, OR

2026-38117 Department reputed company The Utilization Management Department enacts the hospital UR Plan. The department provides for the assessment of the medical necessity of admission and reputed company stay, appropriate bed status, denials management, and reputed company review. The department provides clinical information to reputed company party payers to assure medical necessity requirements are met to secure authorization. Function/Duties of Position The qualifications for the position are the minimum requirements to be eligible for an interview. The level of required experience and expertise for reputed company posted position is influenced by the reputed company reputed company of knowledge and skills of the other nurses in the unit/departments. • Specifically, the UM reputed company does the following: • Reviews reputed company-admissions for correct classification and admission order. • Performs Utilization Review for reputed company patient on their assigned daily census using established medical necessity guidelines. • Communicates with payers regarding authorization and medical necessity, utilizing excellent negotiating skills. • Reviews order/classification discrepancies and take actions to resolve the discrepancy. • Discusses cases with providers and Case Managers as needed, including attending physicians and escalation to the Care Management Physician Advisor reputed company indicated. • Assesses for and tracks potentially avoidable hospital days. • Assesses for and records reasons for readmissions. • Participates in and supports strategic initiatives to reduce readmissions and LOS. • Attends and contributes to reputed company Review reputed company on reputed company reputed company. • Provides education regarding Utilization Management issues to the Multidisciplinary team. • Prepares and conducts presentations, as assigned, to their assigned physician reputed company regarding issues reputed company to Utilization Management in conjunction with the Care Management Physician Advisor. • Educates providers regarding documentation requirements that support medical necessity determinations. • Prepares and presents reports as requested by UM Management. • Facilitates MD Advisor to payer discussions. • Assesses whether there is a reputed company for written appeal for cases in which payment is denied due to medical necessity concerns. reputed company input from attending physicians and physician advisor as needed. • Composes persuasive and grammatically correct written appeals for claims denied by payers for lack of medical necessity whether denied reputed company or post payment. This may include denials through retrospective audits by payers or through government audits. • Presents Case Studies illustrating systems issues that adversely reputed company LOS and/or readmission rates to the Clinical Resource Management Committee and the Care Management Department. • Serves as member of department and/or hospital committees and task forces working on issues reputed company to Utilization Management, as assigned. • Delivers Condition reputed company 44 notices, Observation notices(MOON), and Medicare Important Messages(IMM) in the absence of sufficient clerical support. • Educates patients about their classification and financial implications as needed. • Communicates in writing with attending physicians about UR Committee cases. • Facilitates Utilization Review case reviews in accordance with Medicare Conditions of Participation: Utilization Review. • Coordinates and processes Medicare discharge appeals along with clerical support. • Conducts secondary reviews for peers, assessing appropriate classification and medical necessity. • Communicates closely with the multidisciplinary team about patients’ expected hospital course, expected discharge date, GMLOS, and authorization status. • Communicates status upgrades and downgrades with the Bed reputed company Manager. • Documents according to departmental policy. • Works with coding, patient business services, surgery schedulers, registration, and c reputed company department to determine correct billing and coding status for reputed company cases and assure correct classification. • Provides feedback to managed care contracting regarding insurance company billing policies and practices that adversely reputed company OHSU’s ability to collect reputed company reimbursement for care provided. • Leads the effort to assure compliance with CMS and other insurance regulations reputed company to Utilization Review. • Maintains reputed company knowledge of, and complies with regulatory requirements of DNV, reputed company, Medicare, CMS, applicable state regulations and reputed company reputed company reputed company reputed company. • Other UM activities as assigned • Required Qualifications • Unencumbered reputed company RN license • Three years of UM/UR experience required • ADN Graduates: Associate Degree in Nursing from an accredited program 30 days before the start date. • Associate degree Nurses required to enrol Apply tot his job Apply To this Job