Utilization Review RN

1 month ago

Steubenville, United States Trinity Health System Full time

Job Summary / Purpose

Responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Essential Key Job Responsibilities

Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.  Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes. Collaborates with facility RN Care Coordinators to ensure progression of care. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status. Communicates the need for proper notifications and education in alignment with status changes. Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention. Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate. Establishes and documents a working DRG on each assigned patient at the time of initial review as directed. Demonstrates behavior that aligns with the Mission and Core Values of the Organization. Responsible for completing required education within established timeframes. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice. Participates regularly in performance improvement teams and programs as necessary. Performs other duties as assigned.

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.

Minimum Qualifications

Required Education and Experience 

Required Minimum two (2) years of acute hospital clinical experience or a Master’s degree in Case Management or Nursing field in lieu of 1 year experience. Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.  At least five (5) years of nursing experience.

Required Licensure and Certifications

RN license in the state(s) covered is required.  Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred

Required Minimum Knowledge, Skills, Abilities and Training

BLS required within 3 months of hiring if located within hospital Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used. Proficient in application of clinical guidelines (MCG/InterQual) preferred Knowledge of managed care and payer environment preferred. Must have critical thinking and problem-solving skills. Collaborate effectively with multiple stakeholders Professional communication skills. Understand how utilization management and case management programs integrate. Ability to work as a team player and assist other members of the team where needed. Thrive in a fast paced, self-directed environment. Knowledge of CMS standards and requirements. Proficient in prioritizing work and delegating where indicated. Highly organized with excellent time management skills. undefined

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