RN, Utilization Review

Summary 

The Utilization Review Nurse combines clinical expertise with knowledge of medical appropriateness criteria, and applies principles of utilization and quality management, and the management of clinical/financial resources as a facilitator and consultant to the multidisciplinary patient care team. The Utilization Review Nurse is responsible for review of clinical information documented from providers ensuring clinical data is substantial enough to meet medical necessity criteria and will facilitate the appropriate billing status. 

Essential Duties and Responsibilities  

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned. 

• Demonstrates the knowledge base and essential psychomotor skills required to effectively carry out the job. 

• Demonstrates the ability to interpret, analyze, and apply relevant data to prioritize and determine a course of action appropriate to meet the patients’ clinical needs. 

• Demonstrates effective communication and collaboration with culturally and professional interpersonal skills. 

• Demonstrates effective time management and the initiative to carry out job responsibilities in a timely manner. 

• Effectively assess, plans, implements and evaluates strategies that ensure the appropriate utilization of clinical resources and management of length of stay. 

• Meets all organizational requirements. Demonstrates initiative to establish and achieve personal and professional goals. 

• Demonstrates effective customer service behaviors as defined by the organizations mission, vision and values. 

• Attend required hospital-wide orientations, meetings, and in-services 

• Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care 

Other Job Responsibilities/Expectations include: 

• Using approved   criteria, conduct admission and concurrent chart reviews for Medicare/Medicaid/and managed care payers within appropriate time frame to ensure appropriateness of level of care. 

• Refers cases failing inpatient medical necessity screening to physician advisor for level of care determination when indicated.  

• Monitor length of stay and other ancillary resources use on an ongoing basis. Identify opportunities for process improvement and recommend actions.   Monitor and document on an ongoing basis, avoidable days. 

• Communicates following the chain of command regarding proper utilization of resources, physician concerns, length of stay activities. 

• Coordinate with the department in-house liaison to assure third party certifications when required. Provide information as required regarding denials/approvals. Expedite the peer-to- peer process through collaboration with physician and insurance companies. 

• Communicate denials, verbally and in writing to patients, family, physician as needed. 

• Interacts with patients and families to educate about level of care when necessary or indicated. 

• Delivers observation notices and notices of non-coverage as appropriate to beneficiaries.  

• Works with the interdisciplinary team to communicate level of care determinations.  

• On a concurrent basis, enter all pertinent data (UR and other areas as assigned) in data collections system as per policy/established process. 

• Participates in clinical performance improvement activities as needed and as assigned.   

• Works within the CMSA standards of practice. 

• Ensures compliance with CMS, State and other regulatory agencies. 

• Liaison between attending physician and physician advisor for level of care recommendations, order changes, etc.  

• Assess for appropriate unit of care delivery within hospital and makes recommendations to the treating physician.  

• Works with Revenue Integrity, HIM and other internal departments to ensure billing status is correct.   

• Employee must be proficient in his/her job responsibilities at the end of 90 days.

Qualifications 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Education and Experience  

Minimum Required Education: RN required, 

Preferred Education: BSN preferred 

Experience: Greater than 3 years clinical nursing experience required. Utilization management experience preferred.  Must be self-directed and possess critical thinking and excellent organizational skills. 

Certificates, Licenses, Registrations  

CM certification strongly desirable.  CCM or ACM or any approved certification body required within 2 years of eligibility for the exam