Job Description

UM/RN Case Manager

Position Summary

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Blended role that provides care coordination for patients in the Emergency Department along with medical necessity determination and recommendations for admission and Utilization Management concurrent reviews for ongoing medical necessity for hospitalized patients. The RN functions as a resource and advocate on behalf of the patient and family while assisting in the navigation of the health care delivery continuum by operationalizing multiple processes. Maintains knowledge and skills in area of Utilization Management (UM), medical necessity, determination of proper patient admission status, and application of regulatory and reimbursement requirements of both government and commercial payers.

Responsibilities:

o Utilizes the organizational approved references and software programs to assess medical necessity

Responsible for managing payer relations and requirements to achieve optimum reimbursement and patient outcomes Ensures CMS discharge standards are achieved Provides case management in collaboration with the medical staff, nursing, and ancillary departments throughout the hospital to ensure a safe, timely, transition to the appropriate level of care Assesses medical necessity of acute hospital admission and collaborates with multidisciplinary teams to promote proactive management of continuum of care Applies utilization review to evaluate appropriateness of care setting and level of care Collaborates with Physician Advisors, RN Case Managers, Social Workers and other members of the multidisciplinary team regarding admission status, medical necessity, utilization of resources, and insurance coverages and denials Performs concurrent and retrospective utilization reviews for ongoing stays and tracking of UM metrics related to extended length of stays Assures utilization management compliance of CMS regulations and Conditions of Participation Participates and collaborates with denials and appeals committee Performs other related duties as assigned Familiar with standard concepts, practices, and procedures within the field Relies on experience and judgment to plan and accomplish goals Regular and predictable attendance is an essential job function Competent to meet age specific needs of the unit assigned

Requirements and Minimum Qualifications

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Graduate of a nationally accredited Nursing program State of Idaho Registered Nurse or licensure pending as documented by temporary licensure OR current RN licensure from a state participating in the "multistate privilege to practice" compact with Idaho Licensed RN with a minimum 3 years' patient-facing RN experience at time of hire, ADN or diploma required; BSN or higher preferred All non-BSN RN's with less than 3 years' patient-facing RN experience at time of hire are required to be enrolled in a baccalaureate (or higher) degree program in nursing within 1 year of employment, with completion within 3 years of hire Minimum 3 years clinical practice experience required 1 to 3 years of case management, utilization review, and critical care experience preferred Current Accredited Case Manager (ACM), Certified Case Manager (CCM), Certified Professional Utilization Review (CPUR) or Case Management Administration Certification (CMAC) preferred MCG certification required within 12 months of hire Must be available to work rotational weekends as per department schedule Excellent communication, organizational and interpersonal skills. Ability to work independently and manage time and decisions Proficiency with standard software applications including spreadsheets and word processing required

Working Conditions

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Must be able to maintain a standing and/or sitting position Typical equipment used in an office job Repetitive movements Remote eligible

About Kootenai Health:

Kootenai Health is a highly esteemed healthcare organization serving patients throughout northern Idaho and the Inland Northwest. We have been recognized with many accolades and distinctions, including being a Gallup Great Workplace, No. 1 Best Place to Work in Large Healthcare Organizations, and Magnet(TM) Status for Nursing Excellence. We pride ourselves on our outstanding reputation as an employer and a healthcare provider.

As your next employer, we are excited to offer you:

Kootenai Health offers comprehensive medical plan options, including options for fully paid employer premiums for our full-time employees. For part-time employees, we offer the same plan options with affordable part-time premiums. In addition to medical insurance, we offer many voluntary benefits ranging from dental and vision to life and pet insurance. Kootenai Health also offers well-being resources and telemedicine service options to all employees, regardless of benefit eligibility. Benefits begin on the 1st of the month following 30 days of employment. Kootenai Health's tuition assistance program is available after 90 days. If you want to further your education, we'll help you pay for it Kootenai Health sponsors retirement plans for employees that enable you to save money on a pre-tax and Roth after tax basis for your retirement. Kootenai Health will match your contributions based on years of service ranging from 3-6 percent. Competitive salaries with night, weekend, and PRN shift differentials An award-winning and incentive-driven wellness program. Including a MyHealth corporate team, onsite financial seminars, and coaching Employees receive discounts at The Wellness Bar, PEAK Fitness, and more Robust and interactive employee referral program And much more

If you strive to be an integral part of a high-quality healthcare system like Kootenai Health, we want to meet you!

Apply today! You can also contact the HR Front Desk at 208-625-4620 or email

careers@kh.org

with any questions.

Kootenai Health complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, veteran status, or sex. Kootenai Health does not exclude people or treat them differently because of race, color, national origin, age, disability, veteran status, or sex.






Location: Kootenai Health Trans Care Services - Utilization Mgmt

Schedule: Full Time, Days