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Day - 08 Hour (United States of America)Why work at Stanford Medicine | Stanford Health Care (SHC)?
Here is your opportunity to work with the unique and supportive UM team.
You can put your knowledge about Medicare, Medicaid, and bedside RN experience to great use in this UM role. If you are knowledgeable about InterQual criteria, that is a plus!

Our UM team is a great part of SHC’s efforts in providing and directing the continuity of patient care.

This position requires 4 shifts per month, including weekends and holidays.

This is a Stanford Health Care job.

A Brief Overview
The Utilization Management Registered Nurse (UM RN) will be responsible for ensuring the efficient and effective use of healthcare resources while promoting quality patient care. Working in collaboration with Physician Advisors, Financial Services, Compliance, Denials Management, Patient Access, Clinical Documentation Integrity, Billing, and Revenue Cycle, the UM RN plays an essential role in the financial health of the institution, navigating the complexities of patient care and resource utilization management, and education.

Primary responsibilities include:
1. Coordination with Healthcare Teams: Work closely with other healthcare professionals, patients, and payers to assess, plan, coordinate, monitor, and evaluate the delivery of healthcare services and appropriate levels of care.
2. Medical Records Review: Examine patient medical records to ensure the necessity and appropriateness of care provided.
3. Utilization Review: Conduct thorough utilization reviews, applying evidence-based criteria and guidelines to optimize patient outcomes and manage healthcare costs.
4. Denials and Appeals Management: Address and manage denials by reviewing cases, gathering relevant data, and preparing appeals. Collaborate with physician advisors to ensure clinically sound and persuasive appeals.
5. Physician Advisor Collaboration: Engage with physician advisors on a regular basis to discuss complex cases, seek expert opinions, and ensure evidence-based recommendations are in line with best clinical practices.
6. Continuous Improvement and Education: Stay updated with the latest in clinical guidelines, payer policies, and regulatory requirements to ensure the best patient outcomes and compliance with all standards as well as educate UM team members and practitioners on same.
7. Payer Contracts, Rules, and Regulations: Content expert on rules, regulations, and contracts related to insurance entities and CMS.

The UM RN is a crucial advocate for patients, ensuring they receive the right care at the right time, while also supporting healthcare institutions in their pursuit of both clinical excellence and cost-effective care delivery.

This job description covers all classifications for Utilization Management RNs within the organization. All Utilization Management RNs must meet all elements of the Essential Functions, and Qualifications.
There is a Voluntary professional development program designed to recognize and reward professional excellence in the role of Utilization Management RN. Promotion is determined based on the Utilization Management RN Professional Development Program. Here is a description of the various levels:
Level I: Utilization Management RN
Level II: Advanced Utilization Management RN
Level III: Expert Utilization Management RN

Locations
Stanford Health Care

What you will do

• Utilization Review:
  • Perform timely comprehensive utilization reviews on patient medical records to determine the appropriate level of care, medical necessity, and adherence to Stanford Healthcare (SHC) and regulatory guidelines.
  • Evaluate and analyze patient data, treatment plans, and progress notes to ensure compliance with established standards and guidelines.
  • Identify opportunities for improved resource utilization, cost containment, and quality improvement, utilizing metrics such as the Geometric Mean Length of Stay (GMLOS) to benchmark and guide efficiency efforts.

• Care Coordination Consultation:
  • Consult with healthcare teams as needed, including physicians, nurses, social workers, and other professionals to ensure continuity, appropriateness of care, and optimal use of healthcare resources
  • Facilitate communication and coordination among healthcare providers, patients, and payers to optimize patient progression and minimize unnecessary healthcare services
  • Payer escalation pathways for authorization facilitation
  • EMR Payer access facilitation

• Documentation and Reporting:
  • Maintain accurate and thorough documentation of utilization management activities, including reviews, decisions, and interventions.
  • Generate reports and provide data analysis on utilization metrics, outcomes, and trends to support performance improvement initiatives and compliance with SHC guidelines.
  • Identify opportunities for process improvement and participate in quality assurance activities related to utilization management.

• Compliance and Education:
  • Maintain SHC guidelines, federal and state regulations, payer requirements, and best practices related to utilization management.
  • Educate healthcare professionals and staff on utilization management principles, documentation requirements, and regulatory updates.
  • Collaborate with internal and external stakeholders to ensure compliance with regulatory standards and achieve organizational goals.

• Physician Advisor Collaboration:
  • Consult with the Physician Advisor to discuss complex cases, medical necessity, and strategies for successful appeals.
  • Collaborate with the Physician Advisor to obtain additional clinical information or documentation to strengthen the appeal.
  • Seek guidance from the Physician Advisor regarding medical necessity criteria, coding, and reimbursement policies to ensure accurate and effective appeals and admit orders.

• Denials and Appeal Management
  • Appeals Management
  Review cases that have been denied by insurance providers or other entities and determine the appropriate course of action for appeal.
  Utilize evidence-based clinical guidelines, payer policies, and regulations to construct strong appeals that address denial reasons and emphasize medical necessity.
  Track and analyze denial trends for process improvement.
  • Clinical Collaboration
  Collaborate closely with healthcare teams, including Physician Advisor and other clinical staff, to gather relevant clinical documentation supporting medical necessity and appropriateness of care.
  Assist in educating healthcare providers on documentation requirements and best practices to prevent denials.
  Maintain expertise in costly inpatient-only write-off types by collaborating closely with billing and coding departments to make real-time decisions that affect billing and reimbursement.
  Continuously update inpatient vs. outpatient procedures on data analysis tool to prevent high-cost inpatient-only write-offs.
  • Denial Root-Cause Analysis
  Conduct comprehensive analysis to identify the root causes of denials.
  Implement corrective actions and provide feedback to prevent future denials.
  • Documentation Integrity Assurance
  Review medical records to ensure complete and accurate clinical documentation to support medical necessity.
  • Regulatory Compliance
  Stay current with regulatory policies and guidelines related to clinical appeals.
  Apply regulatory knowledge to strengthen appeal cases.
  Collaborate with internal compliance department on workflows and processes.
  • Billing Support
  Examine accounts listed in the Event Management and Quality Assurance data analysis tool to verify the accuracy of billing information for highlighted accounts.
  Facilitate the processing of patient arrivals, transfers, and discharges within designated units, adhering to provider and payer guidelines to ensure precise billing.
  Offer suggestions and insights to the billing team for potential billing adjustments when necessary.

• Department Operations and Development
  • Engage proactively in department meetings and initiatives, playing a role in shaping processes and ensuring continuous process improvement (i.e., mentoring newcomers, setting measurable outcomes, and aligning with departmental aspirations and budget considerations).
  • Meet or exceed specific targets tied to departmental and regulatory standards, such as reducing hospital stay duration, reducing denials, ensuring appropriate patient class, and lowering re-admission frequencies.
  • Uphold strict adherence to mandated reporting, risk management, and other medical/legal situations while respecting confidentiality policies and maintaining departmental integrity.
  • Drive the design and upkeep of a patient-centric care system. This system should not only be tailored to individual needs but also ensure efficient resource use, facilitate physician practices, and underscore seamless care across various stages.
  • Play a constructive role in team’s decision-making process, collaborate effectively on mutual tasks, and champion the execution of strategies to achieve team goals.
  • Deliver insightful presentations to multidisciplinary teams, shedding light on special assignments, patient care management, and utilization management best practices.
  • Adheres to both departmental and organizational guidelines, actively endorsing core values and forward-looking endeavors.
  • Diligently document patient-related data in a clear and organized manner using standardized templates, capturing essential details such as patient assessments, medical necessity, collaborative communications, and relevant outside agency interactions.

Education Qualifications

• Bachelor's Degree from an accredited college or university required

• Master's Degree Nursing from an accredited college or university preferred

Experience Qualifications

• Three (3) years of progressively responsible and directly related work experience.

Required Knowledge, Skills and Abilities

• Basic knowledge of applicable laws, regulations, and accreditation guidelines (e.g. CMS, DHS, Joint Commission, EMTALA) is required.

• Basic comprehension of both government and private insurance benefits, including but not limited to Medi-Cal, MediCaid, Medicare, DRGs, and managed care, including an understanding of reimbursement requirements.

• A general awareness of available healthcare and community resources suitable for the populations served is required, and a deeper and more extensive knowledge in this area is preferred.

• A working knowledge of InterQual or other nationally accredited utilization review criteria or standards.

• Solid understanding of transitions of care guidelines and utilization management principles.

• Experience in case management, utilization review, or related healthcare roles.

• Strong clinical assessment and critical thinking skills.

• Excellent communication, collaboration, and interpersonal skills.

• Proficiency in utilizing electronic health record (EHR) systems and other healthcare software.

Licenses and Certifications

• CA-RN (Registered Nurse) required and

• CCM - Certified Case Manager required Within 2 Years of Hire or

• Accredited Case Manager - ACM required Within 2 Years of Hire or

• CMGT-BC Nursing Case Management Certification required Within 2 Years of Hire

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family’s perspective:

• Know Me: Anticipate my needs and status to deliver effective care

• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health

• Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $79.21 - $104.97 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.