What are the responsibilities and job description for the Utilization Review RN - Case Management, FT position at Knox Community Hospital?
JOB SUMMARY
Provides utilization review for all hospital inpatients and observation patients. Assists with denial management for any inpatient or observation denial due to case management issues. Utilizes approved criteria to determine appropriateness of patient admissions and observations. Assists in the provision of continuum of care for neonates, infants, pediatric, adult and geriatric patients. Collaborates and communicates with the healthcare team to help ensure quality patient care in a cost-effective timely manner. Documents accurately and in a timely manner. Provides timely clinical reviews and documents progress and/or completion in appropriate documentation system and to third party payers. Collects and reports departmental measures. Adheres to organizational policies and procedures; regulatory/accrediting body requirements; and professional practice standards. Will be cross-trained to function as a Case Manager for the Emergency Department and/or Nursing Care units (refer to job description for Case Management Registered Nurse).
PRIMARY JOB RESPONSIBILITIES
- Performs and documents utilization reviews for all patients that will be admitted or placed in observation.
- Performs continued stay clinical reviews for all patients as required by patient payers.
- Documents clinical review in case management computer program.
- Documents results from utilization review from patient payer.
- Collaborates with healthcare team to establish appropriate level of care.
- Communicates with healthcare team progress of patient approval process.
- Actively promote communication between patient/family and medical staff to maximize outcomes.
- Assists in appealing inpatient and observation denials.
- Assists in the orientation of new personnel and students.
- Assumes responsibility and accountability for individual knowledge, skills performance and behavior in accordance with hospital, division and unit standards of care and policies and procedures.
- Utilizes measures to promote and maintain patient, visitor and personnel safety.
- Maintains patient, employee, physician and organization confidentiality; respects the rights, privacy and property of others.
- Demonstrates knowledge of disaster/emergency procedures and responds appropriately.
- Supports the mission, values and vision of the organization.
ADDITIONAL RESPONSIBILITIES
- Participates in mandatory in-services, staff meetings, educational programs, hospital committees and support groups.
- Presents a professional image.
- Demonstrates initiative in personal/professional development.
- Assists with control of costs through the judicious use of human and materiel resources.
- Other duties as assigned.
EDUCATION AND WORK EXPERIENCE
- Graduate of an accredited program for nursing education, BSN preferred.
- Current licensure to practice professional nursing in the state of Ohio.
- Current American Heart Association (AHA) Healthcare Provider BLS certification required.
- Certification in specialty (case management) is preferred.
- Minimum of 2 years of medical/surgical experience and/or critical care experience required.
- Utilization review experience preferred.
KNOWLEDGE AND SKILLS
- Knowledge and application of criteria utilized to determine appropriate patient status (inpatient / observation / outpatient).
- Knowledge of rules/regulations of Medicare, Medicaid and third party insurers.
- Successful completion of mandatory requirements including, but not limited to, departmental competencies.
- Demonstration of effective problem-solving, decision-making, interpersonal and team-work skills.
- Demonstration of positive customer service.
- Knowledge of the nursing scope of practice.
- Demonstrates effective verbal and written communication skills.
- Basic computer skills.
- Current knowledge of the American Nurses Association (ANA) Code of Ethics.
