Registered Nurse Utilization Review

Duration: 3 Months

The RN Utilization Review II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This RN is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paces, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This RN effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The RN Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of Client.

Responsibilities

•Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine appropriate level of care

•Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system approved tools to track impact and variance

•Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews and clinical appropriateness recommendations

•Coordinate and facilitate correct identification of patient status.

•Analyze quality and comprehensiveness of documentation and collaborates with physician and treatment team to obtain documentation needed to support level of care

•Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses

•Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to work process in order to ensure compliance, i.e. IMM, Code 44

•Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards

•Take appropriate follow-up action when established criteria for utilization of services are not met

•Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance

•Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews

•Proactively review patients at point of entry, prior to admission, to determine medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient

•Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (ie., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)

•Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate

•Proactively identify and resolves issues regarding clinical appropriateness recommendations, coverage, and potential or actual payor denials.

•Maintain consistent communication and exchange of information with payors as per payor or regulatory requirements to coordinate certification of hospital services

•Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care

•Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice

•Analyze assessment data to identify potential problems and formulate goals/outcomes

•Follows the Client Guidelines related the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)

•Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate

•Possesses and demonstrate technology literacy and the ability to work in multiple technology systems

•Act as a catalyst for change in the organization; responds to change with flexibility and adaptability; demonstrates the ability to work together for change

•Translate strategies into action steps; monitors progress and achieves results.

•Demonstrate the confidence, drive and ability to face and overcome challenges and obstacles to achieve organizational goals

•Demonstrate competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of patients served by the department

•Possess negotiating skills which support the ability to interact with physicians, nursing staff, administrative staff, discharge planners, and payers

•Excellent verbal and written communication skills, knowledge of clinical protocol, normative data and health benefit plans, particularly coverage and limitation clauses

•Must adjust to frequently changing workloads and frequent interruptions

•May be asked to work overtime or take call

•May be asked to travel to other facilities to assist as needed

•Demonstrate adherence to the CORE values of Client.

•Other duties as assigned Other Information Education/Skills

• Associate of Nursing Degree required.

•BSN Degree from an accredited nursing program or proven success as Registered Nurse Utilization Review I role

•Familiarity with criteria sets including InterQual and MCG preferred

•Excellent verbal and written communication

•Critical and analytical thinking skills

•Demonstrated clinical competency Licenses, Registrations, or Certifications

•RN License in state of employment or compact required

•CPR certification preferred

•Certification in Case Management preferred Education Included From Job Education Essential Level Assoc Nursing Yes 2 Bachelor of Nursing No 3 Credentials Included From Job Credential Essential RN COMPACT Yes RN SINGLE Yes RN TEMP Yes

Experience Required: 3+ years.

Shift: Day