Registered Nurse Concurrent Utilization Review

3 weeks ago

Tucson, United States Tucson Medical Center Full time

Demonstrates fiscal responsibility related to patient needs, resource utilization, payer requirements and organizational goals. Screens patients for admission criteria (medical necessity/patient status/level of care) utilizing InterQual® criteria and documenting the review in the CERME® software system. Conducts reviews as established by CMS guidelines and Utilization Management processes. Secures authorization/certification for services by communicating necessary and requested information with payors. Communicates information that will impact the discharge plan to the Transitional Care Coordinator and Case Managers to ensure high quality care coordination.

Tucson Medical Center (TMC) is Tucson’s only non-profit community owned hospital. Employees choose to work at TMC because of our values of integrity, community, dedication, and compassion which we show through the exceptional care we provide to our patients and our community. Our passion for caring for the Tucson community has expanded over the last 75 years to include community partnerships, new medical specialties, and medical clinics to further provide the care our community deserves.

**Why Join Tucson Medical Center?**

We don’t only care for our patients, we care for our TMC family too. As a member of our family you can expect to enjoy a wide variety of benefits. In addition to all the benefits you would expect from a leading medical facility (medical, dental, vision, 401K with match) we also provide:

- Family Style Atmosphere with a Supportive Team
- Competitive Pay
- Career Growth Opportunities
- Tuition Reimbursement
- Health and Wellness Coaching

**ESSENTIAL FUNCTIONS**:
Conducts admission, continued stay, outlier, readmit reviews as assigned and per utilization management processes.

Determines appropriate level of care according to InterQual® criteria and other national guidelines, and facilitate movement of patients in a timely manner.

Ensures physician level of care orders are authenticated as necessary.

Determines patient needs and resources through clinical assessments from point of entry to hospital and assists in the discharge planning communication as appropriate.

Refers cases appropriately to Physician Advisor, obtains second level determination and ensures appropriate documentation is present in the medical record.

Obtains required authorization/certification and ensures appropriate documentation is present in the medical record.

Maintains confidentiality of all patient information following our HIPPA guidelines.

Discusses patient status and care with physician team and nursing staff as appropriate. Collaborate with staff, physicians, care/service coordinators, payers, patients, and their families to coordinate and provide the level of care necessary to meet member’s health need.

Utilizes the CERME® software system to document reviews, assessments and progress notes. Documents case status in Epic as appropriate. Documents the necessary process for utilization of Condition Code 44 to ensure appropriate patient/patient representative notification and billing.

Helps others understand issues and differences that impact the plan of care.

Provides communication to case management team members, nursing, and medical staff providers.

Reports any concerns regarding coordination of patient care to the appropriate personnel/process (e.g. Manager, Director, Peer Review, RL®).

Able to manage assignments, if workload is increased, prioritizes so vital activities are accomplished.

Facilities multi-disciplinary teams approach when organizing the coordination of care or resources.

Serves on departmental/hospital team or committee when asked to do so.

Attends all other assigned committee/task force meetings unless excused by Director or Manager.

Assumes responsibility for understanding the posted "hard" copies & electronic departmental agency minutes/memos.

Participates in meetings by taking part in discussions, contributing ideas based on TMC’s best interest rather than own self-interest, volunteering to take on responsibilities, problem solving, facilitating reaching a consensus & fulfilling assigned responsibilities by the deadline.

Participates in performance improvement data collection and/or problem resolution when assigned.

Practices cost-effectiveness with judicious use of supplies, equipment and resources.

Shares information from in-services/workshops/seminars/conferences with departmental team.

Follows and maintains compliance with regulatory agency requirements.

Acts as an education resource to the clinical community and organizational leadership with regards to local, state and federal compliance issues.

Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.

Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.

Performs related duties as assigned

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