Utilization Management Nurse

Job title: Utilization Management Nurse

Company: Children’s Hospital of Philadelphia

Job description: ​Location: LOC_MAIN-Main Hospital

Req ID: 205351

Shift: Any

Employment Status: Regular – Full Time

​About Us

We’re seeking breakthrough makers! Children’s Hospital of Philadelphia was built on the belief that we can change lives. Today, in every role throughout our hospital, research institute and care network, the 22,000 members of our workforce are finding new ways – big and small – to make a difference for the patients and families we serve.

If you are ready to challenge yourself, be inspired and grow – no matter what your role – you just may be the kind of breakthrough maker who will thrive at CHOP.

​CHOP is proud to share that we are ranked No. 1 on Forbes’ 2022 list of America’s Best Large Employers!

Job Summary

Under the general supervision of the Sr. Director, Case Management the Utilization Management Nurse provides comprehensive assessment, coordination, implementation and reporting of complex clinical data. The Utilization Management Nurse assesses the patient’s plan of care and progress of the patient throughout an acute care admission. The intensity of assessment is situational and appropriate based on payer requirements. This position is accountable for the communication of the clinical services delivered to identified payers and agencies

Job Responsibilities

Essential Duties and Responsibilities:

  • Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents all case management interventions in the current electronic system.
  • Monitors and updates accommodation codes and patient types (observation/inpatient), to ensure capture of status and level of care.
  • Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians. Recommends alternative care sites where appropriate.
  • Updates discharge list for last covered day. Calls discharge date to payer or submit discharge review.
  • All new admission reviews are to be completed within 1 business day.
  • Confirmation of pre-certification or authorization for admission.
  • Interqual Criteria is to be utilized with each new admission as well as with every denial.
  • Inform the case manager of any issues or plans noted in the documentation.
  • Self-Pay cases should be referred to Family Health Coverage Program (FHCP) and/or Social Work to determine if coverage is pending or if application for coverage has been made.

Concurrent review

  • All concurrent reviews are completed on the first uncovered day unless specified otherwise by the payer.
  • Reviews are to include current medical status with supporting labs, study results and treatments which are relevant to the level and acuity of care, procedures, surgeries, plan of care and patient progress towards goal, provide any contributing social, educational or discharge planning issues.
  • Reviews requested after the patient has been discharged should be provided within 24 hours of discharge.
  • Determinations should be received and documented within 24 hours or on the next business day following the review or the provision of additional information.
  • All requests from the payer are to be responded to on the day received or within one business day.

Denial Management

  • If notified of a denial or an impending denial notify the attending physician with a phone number to call for a Peer to Peer call.
  • The attending physician is contacted to clarify the level of service and/or the severity of illness, if this information is not clearly reflected in the patient progress notes. When continued inpatient stay cannot be justified and a plan for appropriate level of care is not implemented notify the CM physician advisor for a 2nd level review.
  • It is the responsibility of the UM Nurse to contact and educate the attending physician when documentation does not support the medical necessity for acute level of care or the admission was not pre-certified as required by the health plan.
  • Collaborates with third party payers to prevent denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial when possible.
  • Supports the effective prevention and management of denials, including providing requested information as part of the appeal process.
  • Establishes and maintains rapport with Business Office and collaborates to facilitate timely and appropriate reimbursement for services provided.

Job Responsibilities (Continued)

Other Responsibilities:

  • Adheres to established departmental policies, procedures, and objectives.
  • Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
  • Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
  • Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position.
  • Demonstrates a courteous and professional manner through interactions with internal and external customers.
  • Integrates scientific principles and research based knowledge in decision making.
  • Exemplifies a professional image in appearance, manner and presentation.
  • Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
  • Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
  • Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style.
  • Performs other related duties as assigned.

Job Responsibilities (Continued)

Required Licenses, Certifications, Registrations

Registered Nursing License in the Commonwealth of Pennsylvania or State of New Jersey

Required Education and Experience

Required Education: Nursing Diploma

Required Experience: Minimum of five (5) years’ experience as clinical nurse in an acute care setting.

Preferred Education, Experience & Cert/Lic

Preferred Education: BSN.

Preferred Experience: Prior experience as a Case Manager or Utilization Reviewer

Additional Technical Requirements

  • Excellent communication skills and demonstrated organizational skills.
  • Ability to work effectively with all departments and all levels of CHOP professionals.
  • Ability to work independently or within a team structure.
  • Must be very organized and able to work independently.
  • Ability to establish priorities among multiple needs, meet deadlines and maintain standards of productivity.
  • Knowledge of managed care admission process (i.e. verification of benefits, admissions notification).
  • Ability to effectively negotiate with internal and external providers of patient care services.
  • Sound problem solving skills.
  • Excellent customer service orientation and strong interpersonal skills.
  • Computer skills and a working knowledge of Word, Excel and Access.

To carry out its mission, it is of critical importance for the Children’s Hospital of Philadelphia (CHOP) to keep our patients, families and workforce safe and healthy and to support the health of our global community. In keeping with this, CHOP has mandated all workforce members on site at any CHOP location for any portion of their time be vaccinated for COVID-19 as a condition of employment. This mandate also applies to workforce members performing work for CHOP at non-CHOP locations. Additionally, all workforce members based in or regularly scheduled to work at any New Jersey location are mandated to be both vaccinated and boosted for COVID-19, with booster timing consistent with applicable guidelines. The CHOP COVID-19 vaccine mandate is in alignment with applicable local, state and federal mandates. CHOP also requires all workforce members who work in patient care buildings or who provide patient care to receive an annual influenza vaccine. Employees may request exemption consideration for CHOP vaccine requirements for valid religious and medical reasons. Please note start dates may be delayed until candidates are fully immunized or valid exemption requests are reviewed. In addition, candidates other than those in positions with regularly scheduled hours in New Jersey, must attest to not using tobacco products.

EEO / VEVRAA Federal Contractor


Expected salary:

Location: Philadelphia, PA

Job date: Fri, 05 Aug 2022 07:55:02 GMT

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