Job Description

JOB TITLE: Nurse, Utilization Management Analyst

SUPERSEDES: 05/08, 10/16, 01/19, 04/21 (Utilization Management Analyst)

FLSA: Exempt

JOB CODE: 9459

ISSUED: 05/2008

REVISED: 08/2023

BASIC FUNCTION AND RESPONSIBILITY 

The Nurse, Utilization Management Analyst will perform admission, concurrent, and retrospective review of patient clinical records using pre-established objective quality of care criteria. This role ensures medically necessary care is delivered in the most cost-effective setting while maintaining quality care, monitor reimbursement for hospital services provided to patients, and instruct members of the healthcare team on reimbursement guidelines.

ESSENTIAL FUNCTIONS

Monitor unscheduled admissions to ensure appropriate patient type, timely notification of payor, and identify appropriate target LOS. 

Pre-certify/preauthorize process as assigned. 

Monitor 23-hour observation to ensure conversion to inpatient status if appropriate or discharge. 

Assist with denial and appeal process. Document avoidable delays/days. 

Monitor and develop plans of action for patients with extended LOS over that allowed by the benefit plan. 

Monitor admissions according to all third-party criteria. 

Perform retrospective reviews as necessary. 

Collaborate with payor reviewers to ensure appropriate utilization of resources. 

Provide formal and informal education/in-services to staff and physicians on utilization issues. 

Assist with the development/revision of policies, procedures, and service standards. 

Participate in ongoing efforts to improve the utilization management process and CQI activities as assigned. 

Maintain current knowledge of payor criteria/policies related to utilization of resources. 

Audit charts per request of Patient Accounts and Revenue Recovery. 

Compile data and statistics for monthly and annual reporting. 

Maintain clinical expertise in Medical-Surgical, Pediatric, and Psychiatric clinical care. Escalate payer issues to attending physicians and hospital leadership. 

Actively collaborates with the health care team regarding the course of care delivery to ensure timely discharge. Serve as liaison between the payer and the physician. 

Utilize medical discernment and critical thinking skills on a case-by-case basis as required for reimbursement maximization. 

Participate in formal education of payer criteria policies to medical students and Residents. 

May complete unit/department specific duties and expectations as outlined in department documents.

KNOWLEDGE, SKILLS AND ABILITIES 

Excellent written and verbal communication skills. 

Knowledge of government and private insurance payer guidelines and regulations.

Knowledge in the application of InterQual and/or Milliman Criteria.

SUPERVISION RECEIVED 

General supervision is received from the assigned supervisor or designee.

SUPERVISION EXERCISED 

None

REQUIRED QUALIFICATIONS 

Missouri Board of Nursing RN or Nurse Licensure Compact multi-state RN. When primary state of residency changes, compact state RNs must apply under new state of residency within thirty (30) days. 

Two (2) years of hospital clinical experience or two (2) years of current utilization review experience.

PREFERRED QUALIFICATIONS 

Experience in tertiary care and/or a teaching hospital. 

Experience in conflict resolution strongly desired. 

Additional license/certification requirements as determined by the hiring department.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. The employee may be required ambulate, remain in a stationary position and position self to reach and/or move objects above the shoulders and below the knees. The employee may be required to move objects up to 10 lbs. 

PERFORMANCE EXPECTATIONS 

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job; however, completion of these duties is a measure of successful performance. Employees of this job classification are subject to performance reviews. Basic function, responsibilities and characteristics duties may change at any time with or without notice.

SAFETY SENSITIVE STATUS 

This position is considered safety sensitive. 

This document is a general description of typical job duties, responsibilities and qualifications of employees holding the associated job title. Additional duties, specific qualifications and work emphasis may vary between individual positions.