SENIOR INPATIENT UTILIZATION REVIEW NURSE

Job Summary:

Under the direction and oversight of the Supervisor of Utilization Management, the Senior Inpatient Utilization Review Nurse is responsible and accountable for coordination of services for members of Vivant Health, LLC admitted to and/or discharged from an inpatient acute or skilled facility as well as outpatient services as delegated. The Senior Inpatient Utilization Review Nurse coordinates all systems/services needed for an organized, multidisciplinary, patient centered team approach, and cost-effective care for Managed Medi-Cal patients. The Senior Inpatient Utilization Review Nurse follows and manages the course of treatment for patients while coordinating care with physicians, nurses, case managers and other staff from outside and within the Company to ensure quality care and safe outcomes.  The Senior Inpatient Utilization Review Nurse also conducts initial and ongoing assessments, incorporates disease management protocols, ensures continuity of care through discharge planning and utilization of resources, and refers to the health plans as applicable.

Responsibilities:

• This level serves as a team lead and responds to the most complex medical issues, ensures consistency in the benefit application, may lead cross functional teams, projects, initiatives, process improvement activities.
• This level also serves as a proctor to new hires and participates in the training and/or retraining of lower-level nurses. Performs related duties consistent with the scope and intent of the position.
• Assists with development of care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.
• Responsible for managing a continuum of care from admission through discharge for assigned patients either inpatient or outpatient.
  • Partners with medical staff, utilizes scientific evidence for best practices, relevant data and compliance with the mission/philosophy, standards, goals and core values.  
• Proactively assesses all potential case management and CCS member cases identified from either external or internal sources and actively manages all high-risk, high-volume cases throughout the continuum of the member’s health care needs or until they reach a maintenance mode.
• Demonstrates a multidisciplinary approach in identifying problems, communication and negotiating with the member’s PCP, family members, caregivers, other members of the health care team, community resources and the Health Plans. 
• Researches and refers members to sources for alternative funding, community services and other services which may provide support to the patient and family.
• Tracks all CCS referrals for timely notification of decisions.  Assists Medical Director with CCS appeals as applicable.
• Coordinates care for CCS members between PCP, CCS providers and other physicians and providers as needed as applicable. 
• Identifies cases for possible peer reviewers to evaluate the appropriateness and necessity of care and or quality of care concerns.
• Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing inpatient and outpatient care.
• Performs concurrent review (possibly onsite) for inpatient and/or outpatient and case management to ensure appropriateness of admission, continued inpatient/acute rehabilitation/SNF status, level of care, and discharge using established Milliman guidelines (MCG) or industry standards. Optimize quality of care and utilize cost effective standards of practice. 
• May collect and report utilization data and quality information, such as delays in service, possible avoidable days, provider preventable conditions, readmissions, and length of stays, as applicable.
• Will be required to review Requests for Authorizations and approve and/or refer to Medical Director/Chief Medical Officer for review and denial/modification.
• Applies managed care techniques to clinical practice within established criteria.
• Provides instruction to hospitalized members and their families; and serves as liaison between the member, the physician, the hospital, and the Plan. 
• Authorize home health visits as needed; arrange for admissions to ancillary medical facilities (e.g., skilled nursing facility, sub-acute, intermediate care facility, transfer to other acute hospitals, long term care waivers etc.); and secure other specialty services as needed under the supervision of the attending physician. 
• Processes PDR requests, as applicable
• Process provider disputes, retro requests, and reconsiderations, as applicable. 
• May also refer to social worker, complex case management, or other carve out services as needed.
• Completes appropriate, accurate and timely documentation into EMR system every shift.
• Reports questionable admissions, level of care, length of stays to the Medical Director/Chief Medical Officer and Sr. Director of UM, and as directed, reports quality of care issues to the Sr. Director of UM or Medical Director/Chief medical Officer.
• Provides ongoing evaluations of UM nursing activities according to the standards established by the Company, as well as the physicians and hospitals.
• Assists in preparing UM/QI case issues, gathering requested records/responses.
• Compliant with all departmental metrics: turnaround time, quality audits and productivity standards. 
• Possess knowledge of applicable regulatory standards and performs audits based upon these standards.
• Performs related duties consistent with the scope and intent of the position.
• Regular attendance.
• Travel as required.

Other Functions

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
• Maintain IPA, Health Plan compliance standards.

Competencies

• Four (4) years professional nursing experience in an acute care setting or outpatient setting preferred.
• Four (4) years utilization/case management experience in the managed care industry preferred.
• Medicaid Experience preferred.
• Strong oral and written communication skills, with the ability to communicate. professionally with diverse individuals and groups inside and outside of Vivant.
• Excellent active listening and critical thinking skills.
• Strong analytical skills.
• Ability to solve mid-level problems with minimal supervision.
• Has the ability to be a leader for the department, shows leadership skills and initiative. 
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers/members.
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
• Ability to consistently deliver excellent customer service.
• Excellent attention to detail and ability to document information accurately.
• Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrated excellence in project management and organization.
• Builds partnerships and works collaboratively with others to meet shared objectives. 
• Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Ability to work independently as well as in a team environment. 
• Demonstrate commitment to the organization’s mission.
• Ability to present self in a professional manner and represent the Company image.

Education and Licensure

• High School Diploma or GED minimum requirement.
• Certificate or Diploma from an accredited school of nursing required.
• Active and Unrestricted Licensed Vocational Nurse CA License required.
• Active and Unrestricted RN License Preferred.
• Active and unrestricted Driver’s License.
• Current Auto Insurance.

Travel

• The incumbent may travel up to 75% of the time.

Work Environment 

This job operates in a professional office environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets