The UR-Denial RNs role is to maintain Revenue Integrity and Compliance as outlined within the hospital Conditions of Participation specifically the Utilization Review Chapter. Essential functions of the role are utilization review of all payers, including but not limited to screening for medical necessity upon admission, concurrently and retrospectively; assisting physicians in assuring documentation accurately reflects plan of care, barriers to care, etc.; managing denials via appeals, peer to peer discussions; high awareness of under and over utilization of services; managing concurrent denials; physician and peer education of levels of care; focuses on LOS management by DRG/payer and expected LOS.
• Greeting customers, patients and co-workers with a friendly smile and using AIDET when appropriate (Acknowledge, Introduce, Duration, Explanation, Thank You).
• Listens carefully and avoids interruptions in interactions with both patients and co-workers
• Acts as a role model for co-workers within the department or EMMC.
• Adheres to badge, dress code, tobacco and other personal appearance policies
• Maintains and exhibits a professional, positive attitude towards co-workers, work, and EMMC.
• Demonstrates a commitment to co-workers, job duties, and EMMC (e.g., team player).
• Appropriately focuses on customer needs and expectations as part of the care team, making referrals or transitions when necessary
• Communication is clear, concise, complete and accurate with each interaction
• Is respectful of patients, families, staff, peers
• Effectively facilitates communication between all members of the care team, including the payer
• Supports RN care managers by being a resource for information regarding UR
• Is able to negotiate with payers
• Supports and embraces change in job and EMMC.
• Proactively seeks out solutions to problems for self, co-workers, patients, and visitors.
• Continually develops skills and/or job knowledge.
• Participates in skills training opportunities available to him/her.
• Takes pride in the appearance and growth of EMMC and acts in a way to promote the same
• Is engaged in advancing EMMC to provide top notch quality and safe patient care
• Supports members of the department by orienting staff, coaching, modeling standards of behavior, eliminating behavior which is not kind, helpful, appropriate or conducive to work environment
• Completed iCare training as required for prior year.
• Adheres to “EMMC Code of Conduct” and follows all applicable compliance policies/regulations.
• Works safely and follows all safety policies; reports incidents or hazards immediately.
• Practices appropriate hand hygiene policies
• Seeks ways to improve quality of services provided
• Remains competent in IQ by passing grade of Inter-Rate Reliability
• Provides excellent customer service, both for internal and/or external customers.
• Responds to communications (phone calls, voice mail messages, and emails) in a timely manner.
• Consistent and reliable attendance, including communication and attempts to find coverage when legitimate issues prevent or inhibit attendance
• Collaborates with care team
• Seeks out ways to reduce operating costs or increase efficiency within role/department.
• Acts in a cost conscious manner with regard to use of supplies.
• Makes effective use of time at work
• Recognizes and acts on opportunities to education of peers, staff and physicians on payer systems, reimbursement and levels of care
• Acts upon avoidable delays
• Does not automatically accept down grade from payer–reviews all cases with medical director
• Successfully manages IM, MOONs, ABN, NON, HINN to patients and families in a supportive, non-threatening manner
Licensed RN with State of Maine in good standing or eligible to obtain. 3 years nursing experience required. Prior Care Management or Utilization Management experience preferred. BLS Required.
Competencies and skills:
* Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
* Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
* Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
* Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
* Registered Nurse
* Associate’s Degree
* Potential exposure to abusive and/or aggressive people.
* Potential exposure to diseases or infections.
* Need to drive to perform responsible duties.
* Potential exposure to hazardous materials.
* Potential exposure to noise levels being uncomfortable.
* Potential exposure to noxious odors.
* Potential exposure to very hot or cold temperatures.
* Work with computers, typing, reading or writing.
* Lifting, moving and loading 20 to 30 pounds.
* Continuous sitting.
* Continuous standing.
* Continuous walking.
Equal Opportunity EmploymentWe are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status