Utilization Management Specialist

Job not on LinkedIn

🔥 2 minutes ago

🦬 Montana – Remote

🦬 Montana – Remote

💵 $37 - $54 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Logan Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Logan Health is a healthcare system founded in 1910 that has been dedicated to providing exceptional care for over a century. Its main medical campus is located in Flathead County, serving a total service area that spans 13 counties, covering nearly 40,000 square miles and a population of more than 600,000. The system includes six hospitals, more than 50 provider clinics, and a variety of other healthcare services, notably including the nation's first rural air ambulance service (A. L. E. R. T. ).

📋 Description

• Review all daily inpatient and observation admissions across the Logan Health system • Evaluate physician documentation and patient data to determine appropriate admission status • Reassess patients throughout their stay to ensure continued criteria for level of care are met • Collaborate with the physician UM Advisor, case management team, and insurance partners to facilitate authorizations and medical necessity reviews • Assist with scheduling and coordinating peer-to-peer physician reviews • Communicate with providers, nurses, and other stakeholders to ensure accurate documentation and smooth care transitions • Identify and address issues that could delay reviews or affect compliance • Utilize electronic medical records for documentation, review, and reporting • Coordinate and facilitate correct identification of patient status using validated criteria • Complete short stay work queue reviews and track and trend results for reporting and education • Identify process and system improvement opportunities and lead performance initiatives • Identify and resolve system process issues, delays, and obstacles affecting utilization management • Answer clinical questions related to medical necessity and patient status • Perform concurrent and retrospective reviews • Assist with insurance denial appeal letters, audit activities, and payer inquiries • Resolve utilization management and patient status issues with stakeholders • Consult appropriate disciplines and departments to expedite care and facilitate accurate documentation • Refer utilization management issues to leadership or appropriate stakeholders and monitor resolution • Participate in development, implementation, teaching, evaluation, and revision of departmental utilization management standards • Participate in orientation of new department staff • Document utilization management, quality, and risk concerns and refer them for follow-up • Work independently while collaborating with the interdisciplinary team

🎯 Requirements

• Current Montana RN License or a multi state compact license with authorization to practice nursing within the state of Montana • Bachelor’s degree in Social Work • Associate’s degree required; Bachelor’s degree preferred • Minimum of five (5) years’ acute care hospital experience required • CCM Certification preferred • Prior experience as an inpatient utilization review nurse or UM specialist preferred • Knowledge in areas of Medicare and Medicaid UM regulations, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management preferred • Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy • Excellent verbal and written communication skills including the ability to communicate effectively with various audiences • Strong computer literacy • Analytical thinking • Acute care (hospital) experience • Must currently reside in the State of Montana • Must pass pre-employment criminal background, reference, drug, health and immunizations, and physical demand screenings

🏖️ Benefits

• Four day work week • Affordable Medical Benefits package • 401(k) with generous immediate employer match • Logan Health Fitness Center Membership Discount! • A supportive, mission-driven nursing culture focused on quality, compassion and person-centered care!