Utilization Review Nurse
3 months ago
Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare's most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch.
MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others.
What We Offer
MarinHealth offers a comprehensive suite of employee benefits that support your health, wellness, and financial security. Our robust Wellness@Work program includes onsite health & fitness classes, discounts, and promotes a healthier lifestyle for employees. We also provide a 403(b) contribution plan and company-funded retirement plan, life insurance, vacation, holiday, and sick leave. These benefits, along with our highly competitive compensation package, make MarinHealth one of the best places to work in the Bay Area. Join us and find your next career at MarinHealth.
External hires are subject to a background check and pre-employment medical screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal, state, and local laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws.
JOB SUMMARY:
The Utilization Review Nurse is responsible for completion of admission, concurrent and retrospective reviews for designated health plans. This function includes appropriate application of standardized criteria and concurrent documentation. As appropriate, the UR nurse will assess for clinical stability and coordinate transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals. The UR nurse is also responsible for initial RAC review prior to submission to Physician Advisor and will appeal medical necessity denials. Denials submitted to the case management department from Patient Financial Services will be reviewed to determine if the medical record has sufficient medical necessity documentation prior to a written appeal. The UR nurse will escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care.
JOB SPECIFICATIONS:
EDUCATION
Bachelor of Science degree in Nursing preferred.
EXPERIENCE
- Three (3) or more years of experience in an acute patient care setting preferably in medical/surgical or critical care.
- Substantial recent experience in utilization review and/or discharge planning in an acute care setting is strongly preferred.
- Experience in applying evidence based criteria related to utilization management.
- Experience using case management software
- Must have the ability to read, write, and follow English verbal and written instructions, and have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills.
- Able to carry out review function and access medical records.
- Must have the ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities.
- Utilization review/discharge planning services appropriate to patients with complex
- Strong attention to detail and accuracy is required.
- Must have the ability to work in a high volume case load environment and deal effectively with rapidly changing priorities.
- Demonstrated ability to work constructively with a broad spectrum of health care professionals is required.
- Must be assertive and creative in problem solving, system planning and management.
- Proficient computer skills are required including use of Electronic Health Record. Microsoft Office Suite Products.
- Must have a working knowledge of current medical treatment plans.
- Basic knowledge of applicable laws, regulations, and accreditation guidelines (e.g. CMS, DHS, Joint Commission, EMTALA) is required.
- Basic knowledge of government and private insurance benefits (e.g. Medi-Cal, Medicare, DRGs, and managed care), including reimbursement requirements is needed.
- General knowledge of available health care and community resources appropriate for populations served is required, broad/in-depth knowledge is preferred.
- A working knowledge of Inter-Qual criteria.
- Current California RN license
- BLS-HP certification required
- National certification in Case Management preferred
ESSENTIAL FUNCTIONS (not modifiable)
Utilization Review
- Applies medical necessity criteria by completing an admission review upon hospital notification same day or within 24 hours.
- Documents the review within 24 hours of notification.
- Completes continued stay review and verifies treatment plan, that services ordered are appropriate, and determine if patient is stable for repatriation to Marin for designated health plans.
- Subsequent reviews are scheduled based on clinical findings and /or at the request of Medical Director.
- All reviews are conducted utilizing the approved criteria as defined by Marin General Utilization Management Plan.
- Issues a denial to the facility in the absence of medical necessity with approval of the Medical Director.
- Reviews discharge criteria and determines with treating facility if patient is ready for a safe discharge.
- Works with the treating facility to ensure the plan of care is expedited and barriers to efficient throughput are identified and corrected.
- Identifies the reported plan of care that outlines the key interventions and outcomes to be achieved each day of the inpatient stay.
- Identifies and refers quality and risk management concerns to appropriate level for corrective action plans and trending.
- The chain of command is utilized or case is referred to Medical Director when appropriate and documented.
- Reviews RAC medical necessity denials to determine if appeal is appropriate.
- Works with the Medical Director on complex RAC denials to determine if case will be appealed by third party reviewer.
- Submits an appeal letter following policy and procedure.
- Reviews non-RAC denials submitted by the Patient Financial Services and submit an appeal letter as appropriate.
- Recommends process or policy changes as necessary to avoid lost revenue as a result of denials/RAC requests/audits.
- Works directly with Medical Director to educate physicians on utilization and .medical necessity.
- Follows timeline for appeal submission indicated by payors or regulatory agencies.
- Avoidable day entries are entered in MIDAS as indicated.
- Tracks response to appeals on a weekly basis and communicates with Patient Financial Services as needed for resolution of denied accounts.
- Reviews, processes, and issues denials to client/responsible party following regulatory guidelines and facility protocols. Collects data for the appeals process.
- Uses personal judgment within broad guidelines to initiate review of inappropriate utilization by physicians and follows-through to resolution (e.g., attending, department chair, utilization management medical director).
- Actively participates in department meetings and operations, including process development or improvement (e.g., department orientation, internal mentor/training programs and initiates, disease and population management strategies, appropriate measures for evaluation of outcomes) and establishment of department goals, objectives, and budget.
- Ensures all applicable department and regulatory targets for productivity and department performance process improvement are attained (e.g., hospital length of stay, average cost per discharge, and re-admission rates, etc.).
- Complies with all reporting requirements for mandated, risk management, and other medical/legal situations consistent with confidentiality policies and department standards.
- Actively contributes to the development and maintenance of a care delivery system which is sensitive to individual patient needs, promotes effective resource utilization, and supports physician practice, while emphasizing coordination across the continuum.
- Positively contributes to team's decision-making process, effectively collaborates with other team members on interdependent tasks, and actively supports implementation of plans to accomplish team objectives.
- Prepares and conducts presentations to multidisciplinary teams related to special projects, case management, etc.
- Adheres to department and facility policies and procedures and supports philosophies and initiatives.
- Maintains accurate, current, and legible patient records using approved forms and format, according to department and entity standards, including patient assessments, plans, interventions, patient/family involvement, outside agency communications, and interdisciplinary contacts.
- Actively participates in ongoing department interviews for Case Managers and Department
- Assistants, effectively recommending selected applicants for hire.
- Recommends or provides necessary training to staff.
- Other duties as assigned.
At MarinHealth, our top priority is the well-being of our employees, patients, and community. As such, we require all employees to receive necessary immunizations, including the measles, mumps, varicella, and seasonal flu vaccinations as a condition of employment and annually thereafter. Additionally, the continued recommendation to obtain a COVID booster vaccination status. We understand that some individuals may require medical or religious exemptions from these requirements, but we remain committed to prioritizing the health and safety of all. Thank you for helping us in our efforts to maintain a healthy and safe environment for all.
The compensation for this role listed on this posting is in compliance with applicable law. The selected candidate's compensation will be determined based on the individual's skills, experience, internal/market equity factors, and qualifications. This posted minimum and maximum range represents the minimum and maximum of what we reasonably expect to compensate for the position. Furthermore, all compensation decisions are ultimately determined in accordance with our compensation philosophy. Compensation for positions covered by collective bargaining agreements are governed by the agreements in the aforementioned document.
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