Utilization Review Nurse Per Diem
1 month ago
Clinical Document-Coding Mgmt
Saint Peter's is the 5th hospital worldwide to earn Magnet status SIX times in a row. Our team of award-winning nurses is growing, and we are looking for talented, compassionate RNs to join our team.
The Utilization Review Nurse Per Diem will:
- Identify appropriate medical information necessary to certify and/or refer cases on admission and on continued stay reviews.
- The review of the medical record includes all pertinent information required by insurance payers including the reason for admission, current symptoms, abnormal lab values, abnormal diagnostics, outpatient condition prior to an admission and response or lack of response to such treatment. Review medication administration record to identify antibiotics administered, dose and frequency, respiratory treatments, medical/surgical and social history. Documentation if discharged from a hospital within 30 days, as well as any pertinent clinical information.
- Performs assigned admission reviews within established time frame in accordance with payer requirements as well as daily reviews for Medicare, Medicaid and managed care companies per their requirements.
- Ensures timely provision of clinical review information to payer as evidenced by no denials for lack of clinical information. Collaborates with patient registration /resource services for issues related to insurance coverage (i.e., correct insurance is not in patient record.
- Whenever possible, manages requests for concurrent reconsiderations as evidenced by the “overturn” of the initial denial decision.
- Initiates collaboration with the Medical Staff or Clinical Documentation Specialists by identifying additional clinical information required for obtaining payer determination for approval of the admission.
- Identifies hospital stays at risk for admission downgrades or denials and involves the Physician Advisor in a timely fashion when assistance is needed.
- Refers cases to the Physician Advisor when a change in level of care or termination of benefits seems applicable based upon criteria for Medicare/Medicaid patients (i.e., certification of acute days versus custodial or SNF).
- Utilizes case management software including utilization criteria guidelines, to capture essential admission clinical review documentation.
- Registered nurse currently licensed to practice in the State of New Jersey.
- Required to have three (3) to five (5) years-nursing experience working in an acute care hospital setting, preferably medical/surgical or critical care.
- Experience should include assessment of a patient’s diagnosis, prognosis, care needs responsible for a patient admission.
- The ability to clinically assess the patient condition for establishing medical necessity justifying an inpatient admission by analyzing medical records, interpreting clinical and laboratory data.
- Must have excellent interpersonal, communication, organizational and computer skills.
- Flexible and able to work independently and part of a team.
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