RN - UTILIZATION MANAGEMENT ANALYST

Location: Columbia, Missouri

Shift:  Flexible days - during business hours. Requires at least 8 hours of work on Saturday/Sunday

Department: Utilization Management

Salary Range: $68,265 - $100,402/year - final salary based on experience

ABOUT THE JOB

MU Health Care is looking for a Utilization Management Analyst RN to join our team. The ideal candidate will possess exceptional communication skills, the ability to collaborate effectively with healthcare teams, and a deep understanding of government and private insurance payer guidelines. Your role will involve overseeing patient admissions, conducting reviews, and ensuring that care is medically necessary and efficient. You'll play a vital role in maximizing reimbursements for hospital services, all while advocating for patients and educating both staff and physicians on utilization issues. Join us in making a difference in healthcare while enhancing your clinical expertise and critical thinking skills. This is more than a job; it's a chance to shape the future of healthcare at MU Health Care.

ABOUT MU HEALTH CARE  
MU Health Care is a growing academic health system in mid-Missouri comprised of multiple hospitals — including the region’s only Level 1 Trauma Center and region’s only Children’s Hospital — and over 50 specialty clinics located throughout the region.
As an MU Health Care employee, you’ll be part of an exceptional team committed to our mission of saving and improving lives. Our core values of inclusion, respect, service, discovery, responsibility and excellence foster a collaborative work environment where you can grow your career.

Learn more about MU Health Care.                Learn more about living in Columbia, MO.

EMPLOYEE BENEFITS

Health, vision and dental insurance coverage starting day one 

Generous paid leave and paid time off, including nine holidays 

Multiple retirement options, including 100% matching up to 8% and full vesting in three years

Tuition assistance for employees (75%) and immediate family members (50%) 

Discounts on cell phone plans, rental cars, gyms, hotels and more

See a comprehensive list of benefits here . 

JOB DUTIES
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.

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.

Equal Opportunity Employer

The University of Missouri System is an Equal Opportunity Employer. Equal Opportunity is and shall be provided for all employees and applicants for employment on the basis of their demonstrated ability and competence without unlawful discrimination on the basis of their race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity, gender expression, age, disability, or protected veteran status, or any other status protected by applicable state or federal law. This policy applies to all employment decisions including, but not limited to, recruiting, hiring, training, promotions, pay practices, benefits, disciplinary actions and terminations. For more information, visit https://www.umsystem.edu/ums/hr/eeo.
All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity, gender expression, age, disability, or protected veteran status, or any other status protected by applicable state or federal law.