Report

Utilization Management Nurse

Min Experience

3 years

Location

Franklin, Tennessee, United States

JobType

full-time

About the job

Info This job is sourced from a job board

Overview

About the role

Description

This position will have well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions. This individual maintains current and accurate knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to UM. The UM Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.

Requirements

Essential Duties & Responsibilities

The essential functions include, but are not limited to the following:

Coordinate and facilitate correct identification of patient status.
- Facilitates optimal reimbursement through accurate certification and denial processes, including complete chart documentation ensuring that the appropriate admission status is ordered.
Coordinate and integrate UM functions.
- Conducts concurrent and retrospective reviews based on Xsolis AI capabilities with usage of Client approved Care Level Score decision matrixes.
- Refers cases for secondary review when appropriate.
- Supports the medical necessity denial and appeal process.
Collaborate with all members of the healthcare team, both internal and external.
- Refers and consults with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.
- Communicate with third party payers regarding patient clinical progress.
- Assists the UM team in educating providers on trends found in medical necessity statuses, authorization, and communication from third-party payers.
Participate in clinical performance improvement activities to achieve set goals.
Demonstrate positive and professional written, verbal, and nonverbal communication skills.
Apply advanced critical thinking and conflict resolution skills using creative approaches.
The responsibilities listed are a general overview of the position and additional duties may be assigned.

Minimum Qualifications (Knowledge, Skills, and Abilities)

Education:

Minimum Licensed Practical Nurse, A.A.S. in Nursing, or BSN

Experience:

Minimum 3-5 years of experience in an acute care hospital setting or equivalent health care experience in utilization management and case management
Knowledge of Medicare rules and regulatory standards
Excellent interpersonal communication, problem-solving, and conflict resolution skills.
Computer skills in word processing, database management, and spreadsheet desirable.
Knowledge in areas of: Medicare and Medicaid UM regulations, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management.

Supervisory Responsibilities

This role does not have any direct reports and is a single contributor role.

Working Environment and Travel Requirements

Work is typically in a normal office administrative environment involving minimal exposure to physical risks. Position requires little to moderate physical activity. Mostly sedentary work exerting up to 10 pounds of force occasionally or a negligible amount of force to lift, carry, push, pull, or otherwise move objects. Work involves sitting most of the time, but may involve walking or standing for brief periods of time. No significant stooping is usually required.

Summary

About Us

Xsolis is an AI-driven technology company with a human-centered approach, fostering collaboration between healthcare providers and payers through real-time transparency, objective data for increased accuracy and alignment of medical necessity decisions, and more efficient outcomes. Dragonfly®, its AI-driven proprietary platform, is the first and only solution to use real-time predictive analytics to continuously assign an objective medical necessity score and assess the anticipated level of care for every patient, enabling more efficiency across the healthcare system. Xsolis is headquartered in Franklin, Tennessee.

Our Values:

Team First
Client Passionate
Always Curious
Deliver Excellence

Xsolis has been ranked on the Inc. 5000 and Deloitte Technology Fast 500 lists in both 2022 and 2023 as a fastest-growing private company, and was named 2022 Best in Business among private companies by the Nashville Business Journal. Xsolis executives have been featured in Becker's Hospital Review, Becker's Payer Issues, Chief Healthcare Executive, CIO Review, Managed Healthcare Executive, Medical Economics, HIT Consultant, Healthcare IT Today, among other leading publications.

For more information, visit www.xsolis.com.

Where We’ll Go Together

Our company will become the new standard for utilization management. You’ll be a core part of realizing that goal and a valued contributor to the culture and climate we wish to create. Our wins are your wins, and we’re dedicated to making you feel your work matters (it truly does).

If any of this speaks to you, let’s get in touch.

Candidates must successfully pass a background check and drug screen prior to beginning employment with XSOLIS.

XSOLIS is an equal opportunity employer that is committed to hiring based upon merit, skills, experience, and qualifications. We recognize the importance of an inclusive and diverse workforce that celebrates all individuals from all walks of life. We encourage everyone to apply regardless of gender identity, race, veteran status, age, sexual orientation, or any other protected class.

All employees of XSOLIS fall under the same security role, which includes access to sensitive information, including proprietary data and PHI.

All official communications from our recruitment team come from emails ending in @xsolis.com or @echo.newtonsoftware.com. Job offers are only extended after a formal interview process, and any offer will come through official channels. You can verify postings on our official careers page: https://www.xsolis.com/about/careers.

About the company

AI-driven healthcare technology for utilization management and collaboration.

Skills

Word Processing

Databases

Spreadsheets