RN, Utilization Management Coordinator

The Utilization Management Coordinator Nurse performs duties consistent with the mission vision and values of Goshen Health. Responsible for performing utilization review (UR) on all patients ensuring that severity of illness and intensity of service is appropriately documented and identified in MCG criteria; therefore proactively working to reduce the incidence of denied hospital stays and maximizing reimbursement by ensuring correct admission status. Assist with providing care coordination to patients during transition from acute care to the next level of care in the continuum as needed. This position involves assessment identifications and coordination of insurance authorization denials and appeals. The Utilization Management Coordination Nurse utilizes advanced clinical skills to review documentation complete UR serve as a resource to physicians collaborate with Acute Care Coordination and Denials Coordinator identify trends and share findings with stakeholders. Additionally will facilitate the provision of care including the assessment planning intervention and evaluation of patient care. Promotes and evaluates the effective utilization of resources using current clinical knowledge awareness of community services to achieve optimal clinical and resource outcomes.

Position Qualifications

Minimum Education

• BSN. Requires and active Indiana license as a Registered Nurse.

Preferred Education

• Masters in Nursing or related health care field

Minimum Experience

• Three years clinical experience. Requires clinical skills and an understanding of medical terminology. Knowledge of computer use and various data base software programs. Ability to adapt and be flexible with frequent change. Strong analytical and critical thinking skills. Strong organizational and interpersonal skills.

Preferred Experience

• Requires clinical skills and an understanding of medical terminology third party payers requirements and reimbursement criteria. Requires ability to apply Intensity of Services and Severity of Illness criteria (MCG). Knowledge of personal computers MCG MIDAS Meditech. Ability to comprehend third party payer contractual arrangements