Utilization Management Specialist RN

Our take on this role

About this role

Review medical necessity and level of care across the health system, and coordinate payer denials and appeals. This position is fully remote at 0.6 FTE.

What could you bring from clinical work?

• Nurses: Your experience using clinical criteria to assess appropriate levels of care could help with medical necessity and level-of-care reviews.

Full job description from Fairview Health Services

Job Overview

Utilization Management Specialist RN (Remote | 0.6 FTE)

Join Fairview as a Utilization Management Specialist RN and play a vital role in ensuring patients receive the right level of care while supporting quality outcomes and reimbursement accuracy. In this fully remote position, you'll leverage your acute care and utilization review expertise to assess medical necessity, obtain authorizations, manage payer denials and appeals, and collaborate with physicians and interdisciplinary teams across the health system. This is an excellent opportunity for an experienced RN who enjoys combining clinical expertise, critical thinking, and healthcare operations in a flexible work-from-home environment.

Responsibilities

• Perform and document timely and accurate utilization management review to ensure compliance with all policies, procedures, regulatory and accreditation requirements.
• Adhere to applicable professional standards using nationally recognized evidence-based clinical criteria and M Health Fairview guidelines to determine the appropriateness of level of care, length of stay and discharge planning.
• Facilitate secondary physician review with the physician advisor and/or attending physician on required cases to ensure accurate level of care assignment and reimbursement.
• Manage resolution of concurrent payer denials through submission and coordination of appeals related to medical necessity (level of care) and tracks all work related to denials/appeals.
• Educate internal members of the health care team on utilization management workflow and managed care concepts.
• Work on a variety of special projects and assume other duties as assigned by the Utilization Review Manager or Supervisor.
• Understand and focus on key performance indicators.
• Contribute to the process or enablement of collecting expected reimbursement.
• Understand and adhere to Revenue Cycle’s Escalation Policy.

Required Qualifications

• Bachelors Degree in Nursing
• 3 years or more Utilization Review or Case Management experience in hospital, clinic, insurance company, or long-term care facility.
• 1 year or more of acute care hospital nursing experience.
• MN Registered Nurse (RN) License

Preferred Qualifications

• 1 year Epic experience.
• 1 year experience using medical necessity screening criteria, such as InterQual or MCG.
• 3 years or more of acute care hospital nursing experience.
• Excellent computer and database management skills.

Benefit Overview

Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link foradditional information: https://www.fairview.org/careers/benefits/noncontract

Compensation Disclaimer

An individual's pay rate within the posted range may be determined by various factors, including skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization prioritizes pay equity and considers internal team equity when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign-on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.

EEO Statement
EEO/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status