Hennepin County Medical Center
Staff Nurse - Utilization Review (ED)
Hennepin County Medical Center, Minneapolis, Minnesota, United States, 55400
Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County.
Equal Employment Opportunities:
We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. SUMMARY:
We are currently seeking a
Staff Nurse
to join our Utilization Management department for the Emergency Department. This position is a 0.8 FTE (8 shifts/pay period), 8-hour shifts, Evenings (4:30 pm-1 am), with up to Every Other Weekend rotation. SPECIFIC RESPONSIBILITIES:
The Utilization Review (UR) Registered Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities. Collects, reviews, and documents clinical data relevant to utilization management, including patient status, treatment plans, and healthcare utilization. Identifies expected outcomes related to care transitions, resource use, and reimbursement to optimize patient health outcomes and reduce unnecessary utilization. Develops a utilization management plan by coordinating with clinical teams, payers, and discharge planners to support timely care progression and appropriate resource use. Implements review processes to evaluate necessity and efficiency of services. Continuously evaluates the appropriateness of hospital admissions, continued stays, and treatment plans in accordance with payer guidelines and evidence-based practice. Promotes quality through evidence-based utilization review processes and actively contributes to performance improvement initiatives. Attains and maintains current knowledge in UR/UM practices, payer requirements, clinical guidelines, and regulations affecting utilization management. Evaluates personal practice against professional standards, licensing requirements, and Hennepin Healthcare policies. Collaborates with nursing, providers, case management, finance, and payer representatives. Utilizes principles of relationship-based care to collaborate with care teams, patients, families, and external entities to facilitate effective care coordination and appropriate resource utilization. Applies ethical decision-making when handling authorization issues, appeals, and coverage decisions. Applies evidence-based criteria for utilization review decisions. Considers safety, effectiveness, cost, and legal compliance when recommending levels of care or authorizations. Demonstrates leadership through decision-making, communication with multidisciplinary teams, and proactive problem-solving related to authorization and utilization challenges. Reviews and reflects on own practice related to guidelines, regulations, and departmental goals. Participates in maintaining a safe, efficient, and regulatory-compliant work environment. Demonstrates knowledge and application of adult learning needs and principles. QUALIFICATIONS:
Minimum Qualifications: 1 year of recent utilization review, utilization management or care coordination nursing experience. 1 year of recent professional Emergency Department nursing (RN) experience. Preferred Qualifications: Bachelor's degree in nursing. Certification in area of clinical specialty. Minimum 2 years of recent clinical experience. Strong understanding of utilization review/utilization management principles. Familiarity with InterQual, MCG, or similar clinical decision-making tools. Excellent critical thinking, communication, and documentation skills. Proficiency with EMRs and healthcare documentation systems. License/Certifications: Possession of a valid license as a Registered Nurse issued by the State of Minnesota.
#J-18808-Ljbffr
We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. SUMMARY:
We are currently seeking a
Staff Nurse
to join our Utilization Management department for the Emergency Department. This position is a 0.8 FTE (8 shifts/pay period), 8-hour shifts, Evenings (4:30 pm-1 am), with up to Every Other Weekend rotation. SPECIFIC RESPONSIBILITIES:
The Utilization Review (UR) Registered Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities. Collects, reviews, and documents clinical data relevant to utilization management, including patient status, treatment plans, and healthcare utilization. Identifies expected outcomes related to care transitions, resource use, and reimbursement to optimize patient health outcomes and reduce unnecessary utilization. Develops a utilization management plan by coordinating with clinical teams, payers, and discharge planners to support timely care progression and appropriate resource use. Implements review processes to evaluate necessity and efficiency of services. Continuously evaluates the appropriateness of hospital admissions, continued stays, and treatment plans in accordance with payer guidelines and evidence-based practice. Promotes quality through evidence-based utilization review processes and actively contributes to performance improvement initiatives. Attains and maintains current knowledge in UR/UM practices, payer requirements, clinical guidelines, and regulations affecting utilization management. Evaluates personal practice against professional standards, licensing requirements, and Hennepin Healthcare policies. Collaborates with nursing, providers, case management, finance, and payer representatives. Utilizes principles of relationship-based care to collaborate with care teams, patients, families, and external entities to facilitate effective care coordination and appropriate resource utilization. Applies ethical decision-making when handling authorization issues, appeals, and coverage decisions. Applies evidence-based criteria for utilization review decisions. Considers safety, effectiveness, cost, and legal compliance when recommending levels of care or authorizations. Demonstrates leadership through decision-making, communication with multidisciplinary teams, and proactive problem-solving related to authorization and utilization challenges. Reviews and reflects on own practice related to guidelines, regulations, and departmental goals. Participates in maintaining a safe, efficient, and regulatory-compliant work environment. Demonstrates knowledge and application of adult learning needs and principles. QUALIFICATIONS:
Minimum Qualifications: 1 year of recent utilization review, utilization management or care coordination nursing experience. 1 year of recent professional Emergency Department nursing (RN) experience. Preferred Qualifications: Bachelor's degree in nursing. Certification in area of clinical specialty. Minimum 2 years of recent clinical experience. Strong understanding of utilization review/utilization management principles. Familiarity with InterQual, MCG, or similar clinical decision-making tools. Excellent critical thinking, communication, and documentation skills. Proficiency with EMRs and healthcare documentation systems. License/Certifications: Possession of a valid license as a Registered Nurse issued by the State of Minnesota.
#J-18808-Ljbffr