Utilization Review RN

2 weeks ago

Omaha NE United States Common Spirit Full time

Overview

Utilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and

verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Responsibilities

1. Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to

ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include

admission, concurrent and post discharge for appropriate status determination.

2. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer

Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.

3. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with

providers.

4. Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders

regarding review outcomes.

5. Collaborates with facility RN Care Coordinators to ensure progression of care.

6. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

7. Communicates the need for proper notifications and education in alignment with status changes.

8. Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention.

9. Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate.

10. Establishes and documents a working DRG on each assigned patient at the time of initial review as directed.

11. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.

12. Responsible for completing required education within established timeframes.

13. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.

14. Participates regularly in performance improvement teams and programs as necessary.

15. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.

16. Responsible for completing required education within established timeframes.

17. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.

Qualifications

Graduate of an accredited school of nursing. RN license in the state(s) covered is required.

Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.

BLS required within 3 months of hiring if located within hospital

Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used.

Preferred

Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification

Proficient in application of clinical guidelines (MCG/InterQual) preferred

Knowledge of managed care and payer environment preferred.

Must have critical thinking and problem-solving skills.

Collaborate effectively with multiple stakeholders

Professional communication skills.

Understand how utilization management and case management programs integrate.

Ability to work as a team player and assist other members of the team where needed.

Thrive in a fast paced, self-directed environment.

Knowledge of CMS standards and requirements.

Proficient in prioritizing work and delegating where indicated.

Highly organized with excellent time management skills.

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