Under general direction: The Utilization Management RN serves as a leader resource in the Utilization Management process. They collaborate with physicians and other members of the healthcare team to promote and adhere to regulatory compliance. The UM RN conducts initial concurrent and retrospective medical necessity reviews. All Utilization Management activities are performed in accordance with the mission vision and values of UVA Medical Center.
Analyze and evaluate complex medical documentation:
Demonstrates competence in interpretation of clinical data, and the application of UM tools.
Collaborates with physicians and care team: Attending, resident, mid level practitioners.
Utilizes judgement and critical thinking in determining what cases to refer for second level review to external physician consultants and internal UVA UR MD's.
Provides complete accurate and timely clinical data to Insurance companies.
Utilizes judgement and critical thinking to determine if denied cases will be appealed utilizing medical, contract and payor rules.
Conducts appeals with external entities and Consultants.
Manages appealed cases including external review and resolution for Billing.
Actively supports the financial mission of the department.
Practices according to department standards.
Assumes responsibility for professional development of self and contributes to and assists with the professional development of others.
Demonstrates leadership in the UM role.
In addition to the above job responsibilities, other duties may be assigned.
Position Compensation Range: $59,072.00 - $94,515.20 Annual
Education: Bachelor of Science in Nursing from accredited nursing program.
Experience: 2 years acute care hospital experience.
Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia required.
Job requires sitting for prolonged periods. Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly.
The University of Virginia, including the UVA Health System and the University Physician's Group are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.