**Overview** CHI Saint Joseph Health is one of the largest and most comprehensive health systems in the Commonwealth of Kentucky supporting over 5,000 active employees, 8 hospitals, and a Medical Group with more than 200 locations across Central and Eastern Kentucky. At CHI Saint Joseph Health, we are dedicated to building healthier communities by elevating patient care through high quality healthcare professionals and Humankindness (https://www.chisaintjosephhealth.org/library/landing/humankindness) . We are guided by our strong mission and faith-based heritage, and we're dedicated to providing you with the same level of care you provide to others. We care about our team members well-being and offer benefits that complement work/life balance such as: + Paid Time Off (PTO) + 401(k) and 457(b) Retirement Programs with matching + Medical/Dental/Vision Insurance + Mental Health resources for you and your family + Wellness Program with rewards up to $450 + Tuition Reimbursement for future career growth and development + Adoption Assistance + Voluntary Protection: Accident, Critical Illness, Identify Theft and Pet Insurance + Short and Long Term Disability + Free Premium Membership to Care.com with preloaded credits to support adult and child care needs + Employer Discounts + Relocation Assistance* + Employee Referral Bonuses up to $7,500* _*for eligible hires and positions_ Learn more about our awards and recognitions here: CHI Saint Joseph Health (https://www.chisaintjosephhealth.org/library/default-tab-bar-back/about-us/awards-accreditations) CHI Saint Joseph Health is part of CommonSpirit Health, a nonprofit, Catholic health system dedicated to advancing health for all people. CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health in 2019. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community. Learn more about CommonSpirit Health (https://www.commonspirit.org/) here. Our commitment to serve the common good is delivered through the dedicated work of thousands of physicians advanced practice clinicians nurses and staff; through clinical excellence delivered across a system of 140 hospitals and more than 2200 care centers serving 24 states. **Responsibilities** **Job Summary / Purpose** Responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market. **Essential Key Job Responsibilities** 1. Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination. 2. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility. 3. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. 4. Ensures timely communication and follow upwith physicians, payers, Care Coordinators and other stakeholders regarding review outcomes. 5. Collaborates with facility RN Care Coordinators to ensure progression of care. 6. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status. 7. Communicates the need for proper notifications and education in alignment with status changes. 8. Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention. 9. Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate. 10. Establishes and documents a working DRG on each assigned patient at the time of initial review as directed. 11. Demonstrates behavior that aligns with the Mission and Core Values of the Organization. 12. Responsible for completing required education within established timeframes. 13. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice. 14. Participates regularly in performance improvement teams and programs as necessary. 15. Demonstrates behavior that aligns with the Mission and Core Values of the Organization. 16. Responsible for completing required education within established timeframes. 17. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice. _The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned._ **Qualifications** **Minimum Qualifications** **Required Education and Experience** Required + Graduate of an accredited school of nursing + Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience. **Preferred Education and Experience** Preferred + Bachelor's Degree in Nursing (BSN) or related healthcare field. + At least five (5) years of nursing experience. **Required Licensure and Certifications** + State issued license as a Registered Nurse as outlined below + KentuckyRN:KY or Compact **Preferred Licensure and Certifications** + Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred **Required Minimum Knowledge, Skills, Abilities and Training** + Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used. + Proficient in application of clinical guidelines (MCG/InterQual) preferred + Knowledge of managed care and payer environment preferred. + Must have critical thinking and problem-solving skills. + Collaborate effectively with multiple stakeholders + Professional communication skills. + Understand how utilization management and case management programs integrate. + Ability to work as a team player and assist other members of the team where needed. + Thrive in a fast paced, self-directed environment. + Knowledge of CMS standards and requirements. + Proficient in prioritizing work and delegating where indicated. + Highly organized with excellent time management skills. **Pay Range** $30.47 - $44.19 /hour We are an equal opportunity/affirmative action employer.