Utilization Review RN

7 days ago

Trenton, United States Capital Health (US) Full time

Job Description Work Shift Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview

  • Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care.
  • Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination.
  • Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. .
  • Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry.
  • Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians.
  • Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters.
  • Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program.
  • Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels.
  • Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources.
  • Recognizes and responds appropriately to patient safety and risk factors.
  • Represents Utilization Management at various committees, professional organizations an physician groups as needed.
  • Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care.
  • Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population.
  • Participates in performance improvement activities.
  • Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay.
  • Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes.
  • Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities.
  • Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care.
  • Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols.
  • Maintains related continuing education credits = 15 per calendar year.
Minimum Requirements Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants (including contractors, travelers and consultants) to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.

"Company will never ask candidates for social security numbers or date of birth during application phase. If you are asked for this information online, you may be a target for identity theft."

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