Utilization Review Nurse - RN

Employee is expected to cheerfully and enthusiastically carry out tasks and responsibilities of the job, including but not limited to, high quality professional patient care, thorough and accurate documentation, a willingness to work closely with physicians, administrators, coworkers, and supervisors. Prompt assistance to other units/ departments is expected as well as prompt assistance within the employee’s own unit/ department. By following the guidelines outlined in this job description, high quality patient care will be assured, and the continued success of Curative.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Interacts with providers, facilities and their staff regarding pre-certifications, concurrent review, discharge
  planning, retrospective review, redirections, denials, appeals and complaints and ensuring all assigned
  work is completed by the end of each workday.
• Formulates and promotes continuity of care ensuring appropriate medical treatments, processes and utilization of resources
• Provides concurrent review by assessing the medical necessity and the appropriateness of acute inpatient, SNF, and custodial care in order to justify the continued level of care and identification of avoidable days due to barriers to care
• Provides discharge planning and continuity of care activities including but not limited to home care, DME coordination, follow up with primary care and/or specialist
• Collaborates with the Medical director of Curative, Medical Management Manager and Director of Case Management to develop and implement ways to decrease hospital stays in a medically safe and responsible manner in incorporating criteria based concurrent review techniques, within the parameters of the patient’s health plan
• Work in close coordination with home care delivery systems, outpatient providers and other community agencies to assure follow through of the Utilization Management effort
• Communicates service delivery problems to Manager as identified through the Utilization Management System
• Receives and reviews written and verbal requests for patient services
• Reviews all requests for appropriateness according to established guidelines and coordinated review with plan benefit guidelines
• Receives and reviews requests for services and approves or refers requests for Medical Director review when criteria are not met
• Communicates with case specialist, medical directors, case managers, and other team members on escalations
• Communicates outcome of referral reviews to physician and/ or other office staff and provides authorization numbers
• Participates in special projects as required
• Researches complex cases as needed under the direction of the Manager or Medical Director
• Performs other duties as assigned, not limited to, but including availability to work occasional weekends depending on business needs
• This position assumes and performs other duties as assigned.

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:

• Current knowledge of services provided across the continuum of care that involve multiple systems
  addressing the ongoing needs of the patient
• Knowledge of discharge planning
• Familiarity with community agencies and with how to make appropriate referrals to them
• Knowledge of different hospital reimbursement methodologies and concurrent review criteria
• Excellent verbal and written communication skills
• Computer skills
• Ability to identify ways to decrease hospital days in a medically safe and responsible manner

EDUCATION and/or EXPERIENCE

• Associate or Bachelor Degree in Professional Nursing
• At least four years of clinical experience in hospital nursing such as Critical Care/ER/Med Surg/Home
  Health. One to two years of utilization/case management (managed care preferred). One to two years of
  concurrent review or retrospective review with an emphasis on discharge planning.

CERTIFICATES, LICENSES, REGISTRATIONS

• Unencumbered active RN license in state of primary residence

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters
while performing the essential functions of this job. Reasonable accommodations may be made to enable
individuals with disabilities to perform the essential functions.

• While performing the duties of this Job, the employee is regularly required to sit; use hands to
  handle or feel; talk; and hear.
• The employee is frequently required to reach with hands and arms.
• Specific vision abilities required by this job include close vision, distance vision, color vision,
  peripheral vision, depth perception and ability to adjust focus
• The noise level in the work environment is usually: □ Mild
• The employee may regularly be required to lift and/or move up to: _5_ LBS