Utilization Review Nurse
2 days ago
The utilization review nurse is part of a team that will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation as well as appropriate clinical documentation through extensive interaction with physicians, nursing staff, case managers, other patient caregivers and Health Information Management coding staff to ensure clinical documentation reflects the clinical treatment, decisions, diagnosis and the level of service rendered. The UR nurse serves as a resource to all members of the health care team on appropriate status, documentation guidelines, provide guidance and support, as well as assisting with education and training related to improving clinical documentation on an ongoing basis.
Utilization Review:
* Perform admission, concurrent and retrospective medical reviews to provide to the payers for reimbursement.
* Functions as the liaison between various hospital departments, medical staff and payers on issues related to medical necessity for admission and continued stay.
* The UR/CDI nurse maintains open, transparent and clear lines of communication with the physician advisors.
* Provides UM education to clinical staff as needed.
* Applies standardized criteria and guidelines to assist in the determination of appropriateness of admissions and assignment of patient class (i.e. observation, inpatient and outpatient).
* Assist in monitoring wasted resources while maintaining uncompromisingly high quality of care. Responsible for maintaining and ensuring the admission process remains fully compliant with Medicare and Medicaid regulations.
* Acts as a resource to Care Management department regarding utilization, insurance and payer issues.
* Identifies potential problems regarding payment eligibility for clinical services and recommends corrective action.
* Participates in UR meetings.
Education and/or Experience Required:
* Minimum education (degree/type of degree). BSN
* Minimum experience (minimum years & type of experience). Minimum of 3 years of pediatric clinical experience required.
* KSAs required upon hire or transfer (copy from KSA section below).
Education and/or Experience Preferred:
* Preferred education & experience. Previous UR, case management or care coordination preferred.
License and/or Certification
* Required: RN
* Preferred: ACM
Knowledge, Skills, and Abilities
Knowledge of:
* Knowledge of Pathophysiology and Disease Process.
* Working knowledge of clinical information.
* High degree of familiarity with clinical care to establish credibility with physicians, LIPs, nurses and other members of the front-line care team.
* Must be able to provide clinical and financial education to colleagues, patients and families. Critical thinking, negotiation and the ability to set priorities are of highest importance.
Skilled at:
* Strong interpersonal and communication skills to manage competing priorities of the different stakeholders to ensure provision of high quality, high value and efficient care.
* Electronic medical record.
Ability to:
* Ability to learn/develop the skills necessary to perform Clinical Documentation review of medical records.
* Ability to handle multiple priorities and increasing responsibility.
* Ability to collaborate with others to achieve a common goal through mutual cooperation.
* Ability to influence others for positive and productive outcomes.
* Ability to quickly process complex problems, identify key components, and develop plans for resolution.
* Must be able to learn and use multiple computer systems.
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