Utilization Management Nurse

Nemours is seeking a Full-Time Utilization Management RN to join our team in Wilmington, DE! The Utilization Management Nurse is responsible for the monitoring patient plan of care for timely completion and efficient use of resources by facilitating diagnostic and treatment services, tests, consultations and procedures.  Oversees appropriateness of care using pre-established, health industry standards ensuring the appropriate allocation and use of hospital resources.  Facilitates patient flow during the inpatient stay, identifies and proactively addresses potential denials of payment. Ensures timely and efficient patient throughput of assigned patient populations. Identifies barriers and works collaboratively with the medical and ancillary teams to resolve and expedite safe discharge. Ensures all regulatory requirements related Delaware, New Jersey, Pennsylvania, Maryland and other state agencies are met/updated; further guarantees that care is aligned with:

• The Joint Commission (TJC)


• Centers for Medicare/Medicaid Services


• American Case Management Association Standards of Practice and Scope of Services (ACMA)

The Utilization Management Nurse is accountable for adherence to policies and procedures of Nemours Children’s Hospital, Delaware Valley, and other affiliated hospitals to which Nemours-delegated patients are admitted/seek care. The Utilization and Nurse Case Management Manager is expected to maintain all state and federal clearances for DE.

Essential Functions:

1. Conducts initial clinical reviews within 24 hours of patient admission. All reviews are to follow unit standards as per UM concurrent review guidelines. 


2. Provides concurrent admission, continued stay and retrospective review to insurance company staff as contractually required.


3. Communicates anticipated Length of Stay and insurance review results to interdisciplinary team. Participates in interdisciplinary rounds as indicated.


4. Identifies patients who do not meet current patient class criteria and takes action to communicate and change to appropriate level of care as indicated with attending physician and interdisciplinary team.


5. Converts observation to admission and, conversely, admission to observation status; communicates change to team and others as needed.  


6. Mediates between physicians and insurance companies to avoid denials by monitoring patient plan of care and intervening as needed to assure timely completion of care at appropriate level of care.


7. Facilitates the timely completion of diagnostic tests, procedures and treatment services, consultations and discharge planning activities in collaboration with the case management staff.


8. Monitors payer authorization for continued stay


9. Collaborates with patient care team  to ensure efficient patient throughput. Communicates length of stay authorizations and barriers to discharge to unit based team daily; working within the team to identify and resolve issues.


10. Monitors and facilitates correct patient class and accommodation codes via the EMR for every patient.

     11. Adheres to and participates in revisions to all policies and procedures within the department.

Qualifications:

1. BSN Degree required


2. RN licensure in the state of DE required


3. 5+ years of related experience