Basic Function: The Utilization Management Registered Nurse (UM RN) supports daily coordination of care across healthcare continuum with the healthcare team, community or agency representatives for a positive patient outcome. The UM RN is responsible for preoperative, concurrent and retrospective reviews in accordance with the utilization management program. The UM RN ensures the appropriate level of care is determined and ensures accurate assessment of medical necessity; thus appropriate reimbursement. Requirements: Bachelor’s degree in Nursing or health care related field required. Current registration as a Licensed Registered Professional Nurse in New York State. Two (2) to three (3) years' experience in case management, discharge planning and/or progression of care in the acute-care setting. Understanding of New York State and Federal guidelines and insurance regulations. Minimum one (1) year Utilization Management experience preferred via, industry clinical standards; ie. InterQual, Milliman Care Guidelines. Leadership and management experience, strong communication and interpersonal skills with the ability to mentor others and work effectively and collaboratively with nursing colleagues, physicians and other healthcare professionals and administrators. Responsibilities: • Serves as a subject matter expert and leader in the ever-changing healthcare environment. • Exercise a leadership style that fosters teamwork and collaboration with all hospital staff, post-acute care facilities and providers. • Effectively communicates with the patient, family, physician and health care team to ensure understanding of appropriate management and insurance guidelines and regulations. • Determines appropriate level of care/status via clinical review within 24 hours of registration and/or placement. • Daily review of all observation patients via InterQual or Milliman Care Guidelines. • Collaborates with on-site insurance liaisons to determine appropriate reimbursement and appropriate status. • Escalates reviews timely to physician advisor timely for lack of medical necessity and/or status discrepancies. • Identifies opportunities to reduce cost of managing patient care without compromising outcomes. • Issues denials to those that do not meet medical necessity criteria for hospital admission. • Reports all variances through established outcome management and quality improvement processes. • Identifies and tracks issues that contribute to status changes and denied hospital reimbursement. • Identifies avoidable days via Midas that contributes to increased length of stay. • Carries out work assignments within allotted time-frame. • Accurately documents utilization management activities per policy. • Communicates clearly with all members of patient, family healthcare team, and insurance liaisons. • Continually updates knowledge of nursing theory, insurance criteria, current healthcare trends and available community resources. • Responsible for yearly re-education on industry standard criteria;. InterQual/Milliman Care Guidelines. • Maintains integrity and confidentiality of all data.