Assesses if all days are authorized/certified by respective payers and communicate any issues/denials to attending physician, CM, and department leadership. Conducts UR until all tasks are completed; indicates UM Complete in authorization and/or certification. Communicates with payer UR representatives on status/level of care authorizations that do not match MCG review. Denotes relevant clinical information to proactively communicate with payers for authorizations of treatments, procedures, and Length of Stay; sends clinical information as required by payer. Notifies appropriate parties of any changes in financial class including conversions, Hospital-Issued Notices of Noncoverage (HINN), Condition Code 44, and Important Message from Medicare (IMM). Follows department procedures and policies for Condition Code 44, Physician Advisor review, and HINN processes. Documents Avoidable Days/ Delays, per department process/procedure/policy. Priority 3: Maintains an Active Role in Denial Prevention and Management. Uses payer MCG criteria and supporting documentation to justify the patient’s medical necessity for observation, admission and/or continued stay. Proactively interacts with payers and proactively sends clinical reviews to prevent inpatient denials. Proactively communicates with payer UM representatives on denials and coordinate peer to peer review with payer’s medical director. Initiates and coordinates peer to peer reviews on all concurrent denials. Understands payer requirements and government regulations to ensure compliant, safe, and cost-effective healthcare. Priority 4: Identify Prolonged LOS patients, readmission, or complex discharge needs patients. Identifies Prolonged LOS patients or complex patients/situations and communicate to the CM and/or Social Worker as appropriate. Priority 5: Escalation. Refers cases that require second level review to Physician Advisor, Manager, and Director per department process or procedure. Discusses status/level of care and payment barriers with attending for resolution, if unsuccessful, escalate to department leadership and Physician Advisor, per department process or procedure. Insurance and Utilization Management. Maintains working knowledge of CMS requirements and readmission penalties. Maintains working knowledge of insurance/payer benefits. Documentation. Documents accurately and in a timely manner in the Electronic Medical Record per program guidelines. Utilizes standards of professional practice in all documentation and communication consistent with organization/department policy as well as the Board of Nursing and ethical guidelines established and universally supported by the nursing profession. Assures documentation and patient information is secure and maintained in accordance with Billings Clinic policy, HIPPA, state and federal guidelines. Professional Accountabilities. Participates in continuing education, department planning, work teams and process improvement activities. Maintains current Licensure. Adheres to department and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols and safety. Demonstrates the ability to be flexible, open minded and adaptable to change. Maintains competency in organizational and departmental policies/processes relevant to job performance. Utilizes standards of professional practice in all communication with patients, support systems and colleagues consistent with the Board of Nursing and ethical guidelines established and universally supported by the nursing profession. Maintain utilization review data, as assigned by department. Performs all other duties as assigned or as needed to meet the needs of the department/organization Qualiifications Minimum Qualifications. Education 4 Year / Bachelors Degree Graduate of an accredited school of nursing, bachelor’s degree required Experience 3 years of hospital clinical experience. 1 One (1) year of Billings Clinic experience, preferred. License and Certification Healthcare Provider and ACLS CPR certifications. Current Registered Nurse license in the state of Montana Billings Clinic is Montana’s largest health system serving Montana, Wyoming and the western Dakotas. A not-for-profit organization led by a physician CEO, the health system is governed by a board of community members, nurses and physicians. Billings Clinic includes an integrated multi-specialty group practice, tertiary care hospital and trauma center, based in Billings, Montana. Learn more at Billings Clinic is committed to being an inclusive and welcoming employer, that strives to be kind, safe, and courageous in all we do. As an equal opportunity employer, our policies and processes are designed to achieve fair and equitable treatment of all employees and job applicants. All employees and job applicants will be provided the same treatment in all aspects of the employment relationship, regardless of race, color, religion, sex, gender identity, sexual orientation, pregnancy, marital status, national origin, age, genetic information, military status, and/or disability. To ensure we provide an accessible candidate experience for prospective employees, please let us know if you need any accommodations during the recruitment process.