Utilization Management RN

Under general direction: The Utilization Management RN serves as a leader resource in the Utilization Management process. They collaborate with physicians and other members of the healthcare team to promote and adhere to regulatory compliance. The UM RN conducts initial concurrent and retrospective medical necessity reviews. All Utilization Management activities are performed in accordance with the mission vision and values of UVA Medical Center.

Analyze and evaluate complex medical documentation:
Demonstrates competence in interpretation of clinical data, and the application of UM tools.
Collaborates with physicians and care team: Attending, resident, mid level practitioners.
Utilizes judgement and critical thinking in determining what cases to refer for second level review to external physician consultants and internal UVA UR MD’s.
Provides complete accurate and timely clinical data to Insurance companies.
Utilizes judgement and critical thinking to determine if denied cases will be appealed utilizing medical, contract and payor rules.
Conducts appeals with external entities and Consultants.
Manages appealed cases including external review and resolution for Billing.
Actively supports the financial mission of the department.
Practices according to department standards.
Assumes responsibility for professional development of self and contributes to and assists with the professional development of others.
Demonstrates leadership in the UM role.
In addition to the above job responsibilities, other duties may be assigned.

MINIMUM REQUIREMENTS

Education: Bachelor of Science in Nursing from accredited nursing program.

Experience: 2 years acute care hospital experience.

Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia required.

PHYSICAL DEMANDS

Job requires sitting for prolonged periods. Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly.

The starting base rate for this role is $80,000.00 annually. Individual compensation will be determined by the selected candidate's qualifications, previous work experience, and/or education.

Benefits

Comprehensive Benefits Package: Medical, Dental, and Vision Insurance
Paid Time Off, Long-term and Short-term Disability, Retirement Savings
Health Saving Plans, and Flexible Spending Accounts
Certification and education support
Generous Paid Time Off

UVA Health is a world-class Magnet Recognized academic medical center and health system with a level 1 trauma center. 2023-2024 U.S. News & World Report “Best Hospitals” guide rates UVA Health University Medical Center as “High Performing” in 5 adult specialties and 14 conditions/procedures. We are one of 70 National Cancer Institute designated cancer centers. UVA Health Children’s is named by 2023-2024 U.S. News & World Report as the best children's hospital in Virginia with 9 specialties ranked among the best in the nation. Our footprint also encompasses 3 community hospitals and an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, Northern Virginia, and beyond.

The University of Virginia is an equal opportunity employer. All interested persons are encouraged to apply, including veterans and individuals with disabilities. Learn more about UVA’s commitment to non-discrimination and equal opportunity employment.

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