JOB SUMMARY
The Utilization Review Registered Nurse (RN) provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with the health plan, provider utilization and/or care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates as a team to ensure that medical records support the level of services being delivered.
ESSENTIAL FUNCTIONS OF THE ROLE
Performs initial, concurrent, discharge and retrospective reviews. Uses evidence-based medical guidelines to determine the medical appropriateness of inpatient and outpatient services; Assesses patient needs; Uses knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients; Identifies, escalates and resolves complex cases or issues as required.
Reviews medical records to verify that the content supports an appropriate level of care (inpatient, observation, bedded outpatients) or type of service.
Alerts and collaborates with appropriate Utilization Review, Physician leadership and/or Provider Team personnel concerning patients who do not meet medical appropriateness criteria. Coordinates with necessary parties when there are potential or actual denials. Facilitates appeals or the delivery of appeal instructions when denials occur.
Facilitates authorization process for admissions and continued stays. Uses knowledge of nursing process and pathophysiology to anticipate discharge needs. May participate in discharge planning through discussions with the care team as needed.
Communicates issues or trends with specific entities, providers or payors to the appropriate leadership.
Provides support to complex cases or escalations within scope of licensure or refers them to appropriate leadership.
Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.
Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies, and procedures to continuously enrich care coordination efforts and ensure evidence-based processes are utilized.
Performs service recovery efforts to support provider and member satisfaction.
KEY SUCCESS FACTORS
Advanced understanding of health care modalities, pathophysiology, therapies, terminology and equipment.
Advanced understanding of health care modalities, pathophysiology, therapies, terminology and equipment.
Ability to understand the customer’s point of view and take ownership of creating a solution to their issues.
Knowledge and use of discharge planning, case management referral criteria, utilization review and levels of care.
Knowledge of applicable federal and state regulatory requirements, including TDI, CMS, DOL, HHSC and NCQA standards and requirements.
Must be able to communicate thoughts clearly; both verbally and in writing.
Interpersonal skills to interact with a wide-range of constituencies.
Must have critical thinking and problem-solving skills.
Ability to balance multiple demands and respond to time constraints.
Ability to analyze, understand and act on detailed clinical care documentation.
General computer skills, including but not limited to Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.
Certified Case Manager (CCM), Accredited Case Manager (ACM), or Certified Managed Care Nurse (CMCN) preferred.
BENEFITS
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
Source: Indeed.com
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