Utilization Review Nurse

5 days ago

Spencer, United States HexaQuEST Health, Inc. Full time
Job Description:

Please submit qualified candidates with a minimum of 5 years of experience in direct patient care and 3 years in a Utilization Review role.

Schedule:

Standard business hours, Monday to Friday, 8am to 4:30pm.

Responsibilities:
  1. Provide Utilization Review coverage for hospital patient care units.
  2. Assist with admission and continued stay reviews for patients admitted to med-surg, swingbed, behavioral health, ICU/PCU, and OB units.
  3. Review medical records for clear admission orders, documentation of medical necessity for admission and continued stay criteria, using Milliman care guideline criteria.
  4. Perform utilization review activities for Medicare, Medicaid, private insurance, and self-pay patients.
  5. Communicate with Patient Accounts on patient level of care, insurance coverage, authorization numbers, and benefit information.
  6. Enter insurance authorizations obtained into Paragon UR or Patient Management 'Notes' tab.
  7. Prescreen patients before admission to swingbed/skilled level of care, gathering clinical information to ensure qualification.
  8. Communicate with physician and nurse manager of med-surg unit on patient transfers from outside facilities.
  9. Coordinate communication with nursing staff and write orders under physician direction for outside transfers.
  10. Attend med-surg daily updates to remain apprised of patient conditions and provide communication from UR.
  11. Attend Behavioral Health team meetings when needed, to remain apprised of patient conditions and provide communication from UR.
  12. Apprise UR Coordinator of any UR issues that may be significant.
  13. Apprise Risk Manager of any risk issues identified.
  14. Maintain patient confidentiality.
Additional Responsibilities:
  1. Assist with Quality Management Committee & Medical Staff Quality Management Committee (QMC/MSQMC) review process.
  2. Assist with blood transfusion monitoring, reviewing for medical necessity of blood transfusions administered, and referring cases to physician reviews as indicated.
  3. Assist with Mortality and Morbidity (M&M) review, reviewing medical records of deaths that have occurred, completing an M&M worksheet, and completion of the physician review process.
  4. Assist with quality monitoring, i.e. Admission Review monitor, and other topics as indicated.
  5. Maintain peer review confidentiality.
  6. Assist with data collection of any focused review monitoring directed by the MSQMC.
  7. Assist with compiling Medical Staff peer review information for medical staff credentialing and reappointment.
Medicaid Managed Care Reviews:
  1. Assist with communication of Medicaid patients involved with Medicaid Managed care companies, ensuring precertification and continued stay reviews are completed for authorization of services and payment.
  2. Communicate with Patient Accounts on authorizations obtained with patient level of care.
Promote Quality Services Department:
  1. Participate positively in departmental staff meetings.
  2. Assure team approach.
  3. Assist with special projects and committee work as assigned.
Requirements:
  • Must be currently active.
  • Minimum 5 years of experience in direct patient care.
  • Minimum 3 years in a Utilization Review role.
  • Must be able to work standard business hours, Monday to Friday, 8am to 4:30pm.

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