RN-Utilization Review/Case Manage Nurse

GENERAL SUMMARY

Under the general direction and supervision of the Sr. Executive Director of Quality Assurance, this position is responsible for Utilization Review (UR) of hospitalized patients. The UR role encompasses reviewing patient admissions for severity of illness and intensity of service and working closely with the Case Management team, Medical Staff and Nursing units to ensure effective and efficient utilization of services.

GIBSON AREA HOSPITAL & HEALTH SERVICES MISSION STATEMENT

To provide personalized, professional healthcare services to the residents of the Communities we serve.

PRINCIPLE DUTIES AND RESPONSIBILITIES

1. Applies utilization criteria (InterQual, MCG, local and national coverage determinations) to each patient, to validate continued stay, appropriate level of care and readiness for discharge.
2. Provides concurrent reviews of all admissions to determine change of diagnosis, symptoms, problems, patient condition, treatment scheduled, admission status and barriers to care. Documents findings within the patients medical record.
3. Confers with the ED and admitting physicians when documentation does not substantiate inpatient status, offering suggestions for clarity and completeness.
4. Contacts physician advisor for peer review of cases when questions arise or extended length of stay is questioned.
5. Sends updated clinicals to insurance providers on an ongoing basis as per the payer requests.
6. Ensure Peer to Peer Reviews are completed in a timely manner and provide support to the Hospitalist or admitting provider who is doing the Peer to Peer by ensuring needed information is easily and readily available.
7. Conducts current and retrospective appeals. Making sure that the process is timely and communicates the status with the appropriate Revenue Cycle Team members.
8. Tracks timing of notification of admission to Managed Medicare Advantage plans and Managed Medicaid Plans with follow up tracking of the response date and time from the plans.
9. Works with coding professionals to ensure the appropriate final diagnosis and secondary diagnosis are reflective of the true acuity of the patient and medical necessity for the admission.
10. Encourages the appropriate use of health care services and strives to improve quality of care and maintain cost-effectiveness on a case-by-case basis.
11. Monitors for over-utilization or under-utilization of services and reports discrepancies to the Sr. Executive Director of Quality Assurance.
12. Maintains knowledge of current trends and developments by reading literature and attending appropriate seminars, inservices, or conferences.
13. Assists and is involved in the Gibson Area Hospitals continuous quality improvement efforts designed to enhance patient outcomes, increase patient satisfaction, and improve the utilization to the Gibson Area Hospitals human capital and physical resources.
14. Maintains confidentiality of patient information and patient privacy.
15. O Licensed Practical Nurse ther duties as assigned.

PHYSICAL REQUIREMENTS

1. Physical strength to perform the following lifting tasks:

• • Floor to waist - 20 pounds
  • 14 to waist - 30 pounds
  • Waist to shoulder - 20 pounds
  • Shoulder to overhead - 10 pounds
  • Carry 20 pounds for 30 feet
  • Push 10 pounds/force for 15 feet
  • Pull 10 pounds/force for 15 feet

1. Work requires the ability to lift and carry files on a daily basis and standing up to 1 hour if necessary.
2. Work requires communication abilities necessary to assess patients condition and interact with physicians and exchange information with care providers and others on a daily basis, including ability to use telephone.
3. Work requires proofreading and checking documents for accuracy on a daily basis.
4. Work requires ability to use a keyboard to enter and transform words or data on a daily basis. Ability to communicate in writing.
5. Visual acuity necessary to observe patient, obtain information, and use documentation.
6. Auditory acuity necessary to hear patient/family/staff for the purpose of communication.

REPORTING RELATIONSHIP

Directly to the Sr. Executive Director of Quality Assurance, indirectly to the Assistant Director of Case Management.

EDUCATION, KNOWLEDGE AND ABILITIES REQUIRED

1. Current Illinois Registered Nurse with at least five years clinical experience preferred. BSN required. Certification in Case Management, Coding or Clinical Documentation Integrity preferred or willing to obtain within one year of employment.
2. Knowledge and skills necessary to provide utilization and case management of patient care units appropriate to the age of the patient served including infant, pediatric, adult, and geriatric.
3. Knowledge of utilization review interventions and overall understanding of compliance with Severity of Illness and Intensity of Service criteria, use of InterQual/MCG software and local and national coverage determinations.
4. Knowledge of utilization policies, procedures, area of resources, and state and federal regulation.
5. Advanced communication skills are required to interact with patients/So, providers (MD, PA, NP), healthcare team members and outside agencies.
6. Emotional stability to deal with high stress level associated with working with acutely ill patients and maintaining effective working relationships with peers and physicians.
7. Keen mental functions to perform assessment and decision making skills in the management of utilization of the units in the hospital.

INFECTION EXPOSURE RISK LEVEL

Category 2- Low Risk

Position contains tasks that involve no exposure to blood, body fluids, or tissue, but employment may require performing unplanned tasks that do involve exposure.

WORKING CONDITIONS

1. Works in a normal office or patient care environments where there are relatively few discomforts due to dust, dirt, noise, and the like.
2. Works with patients and may be exposed to contagious diseases of infectious material, but potential for person harm and injury is limited when proper safety and health precautions and equipment are used.