Utilization Review RN

Utilization Management RN The Utilization Management RN reports directly to Utilization Review RN Coordinator. The UR RN supports the UR RN Coordinator and other UR team members in providing all identified utilization review functions for the organization to ensure cost effective care delivery. The UR LPN is responsible for completing utilization reviews, referral to MD advisor service(s) to allow for secondary review, contact with providers for notification and to obtain status orders when appropriate; continued stay reviews for cases where admission exceeds the GMLOS, documentation of avoidable, initiation of authorization request and submission of records for post-acute care facilities who are admitting patients from St. Peter's Health. Facilitation of peer to peer calls for both hospital admissions and for specific outpatient service denials as assigned, and participation in the organizations Utilization Review Committee. In collaboration with the patient/family, physicians, and the interdisciplinary team, the UR RN ensures the care delivery systems at SPH are utilized effectively and efficiently; engages the UR RN Coordinator with improvement ideas when deviations of best practice are noted. The UR RN serves as an advocate for the patient and family throughout the continuum of care and serves as a collaborative and supportive liaison and educator to providers and staff around utilization management principles. This professional role will be responsible for: Stay current on insurance issues and proactively educates/notifies UR RN Coordinator of pertinent changes. Maintain confidentiality of hospital, patient, and family information. Must be able to interact with various hospital staff and departments at all levels possessing positive communication skills and compassionate competence. Apply medical knowledge and experience for prior authorization requests. Perform detailed medical reviews of prior authorization request or assessment forms according to established criteria and protocols. Manage incoming authorization requests and inquiries via email, fax, computer, telephone, or mail. Maintain accurate documentation on all requests and documenting in the appropriate computer application. Initiate and continue direct communication with health care providers involved with the care of the patient to obtain complete and accurate information. Follow-up on Peer to Peer requests including scheduling these to be completed between the facility and plan providers. Review insurance companies' requests for change of patient status using MCG guidelines then negotiates with insurers to obtain the maximum payment possible for the claim. Collaborates real-time with medical staff to assure correct admission status and confirm treatment goals, treatment plan, and clinical mileposts used to advance the treatment plan. Coordinate patient information to assure timely reviews according to UR work plan and follow-up with physician consultants. Confirm admission diagnosis and correct admission status and identifies related quality measures to promote medical compliance. Collaborates with admitting physician, ED physicians, Hospitalists, Documentation Specialist, and other ancillary staff to assist with the initial patient assessment and high risk screen for the purpose of resource management. Provide point-of-care coaching to the medical staff for documentation improvement and observance of quality indicators to support admission status. Evaluate denials for appropriateness for appeals versus billing at an alternate level of care. Track and follow-up on submitted appeals, adjustments, and reconsiderations. Work independently to provide coverage for UR activities during weekend days while other UR team members are out of the office. Complete comprehensive review of all admissions to SPH. These are evaluated for admission status. Follow-up daily on all communication with the MD advisor or physician consultant(s) on any cases sent for physician review. Performs daily utilization reviews on all patients admitted the day prior. Continued stay reviews daily. Documentation of avoidable days of care within Epic. Using MCG severity of illness/intensity of service criteria, evaluates the patients' status and need for acute care services to assure appropriateness of the admission status and communicates when needed with the other UR team members. Works closely with hospitalist team providers, outside providers, and staff to assure patients who are admitted are meeting the appropriate criteria for the status order(s). Contact the attending provider for variations in status from that of criteria and/or physician advisor recommendations. Enter appropriate status orders into Epic as they are received for admission status changes deemed appropriate by the attending provider. Participate in orientation of new employees of the UR team. Work in harmony and unison with all personnel of St Peter's Health. Complete and/or attend all required educational offerings annually. Ability to use electronic software applications related to UR activities. Operate copying machine, fax machine, and computer. Handling AV equipment, materials, and supplies. Other duties as assigned to ensure the UR RN's talents are utilized to better the organization. KNOWLEDGE/EXPERIENCE: Minimum of three (3) years of acute care experience desired. Experience with healthcare insurance or utilization management functions preferred. Excellent assessment and analytical skills as well as an ability to effectively communicate with SPH team members and outside providers is an essential requirement for this role. EDUCATION: Clinical preparation; RN required LICENSE/CERTIFICATION/REGISTRY: Nursing licensure in the State of Montana. Certification in Case Management and/or Utilization Review desired. APTITUDES: Excellent interpersonal communication and negotiation skills. Knowledge of community and system resources Strong organizational and time management skills Ability to work independently Word, Excel, and Meditech experience preferred