Utilization Review RN

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The UR RN specializes in examining medical records and developing concise and pertinent clinical reviews to support authorization obtainment, avoid payment denial, and optimize reimbursement. The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination.

The Utilization Management Case Manager is responsible for performing the initial and concurrent Utilization Reviews on all patients admitted or placed in outpatient status with observation services. MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE

1. Three (3) years of healthcare clinical experience.

EDUCATION, CERTIFICATION, AND/OR LICENSURE

1. Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

EXPERIENCE

1. Medical Management for Medicare and/or Medicaid populations.

2. Utilization Management experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assure effective communication of medical necessity to the applicable payor.

2. Reviews, assesses, and evaluates clinical information used to support Utilization Management (UM) decisions based on medical record documentation.

3. Facilitates professional communication to ensure the authorization process is completed in a patient centered manner with adherence to quality and timeline standards.

4. Reviews medical records and compiles concise and pertinent clinical reviews.

5. Collaborates with UR coordinators, clinical appeals, and physician advisors to prevent and manage concurrent denials.

6. Advocates for the patient and hospital with insurance companies to optimize reimbursement and hospital stay coverage

7. Collaborates with other members of the interdisciplinary team as outlined in the system UM Plan

8. Provides timely and comprehensive documentation of clinical reviews and payor communication.

9. Maintains working knowledge of payor requirements.

10. Communicates concurrent denials to appropriate team members in a timely fashion.

11. Provide highly effective reconsideration clinicals to payors in order to prevent denials

12. Liaise with hospital case management as necessary and appropriate

13. Maintains effective and efficient processes for determining appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers.

14. Maintains knowledge and understanding of applicable federal regulations and Conditions of Participation.

15. Actively participates in process improvement initiatives, working with a variety of departments and multidisciplinary staff.

16. Effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.

17. Identify delays in treatment or inappropriate utilization and serves as a resource

18. Coordinates communication with physicians and collaborates to ensure appropriate patient status.

19. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.

20. Consistently demonstrate ability to serve as a role model and change agent by promoting the concept of teamwork and the revenue cycle process continuum of high performing teams.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office work which includes sitting for extended periods of time.

2. Must have reading and comprehension ability.

3. Visual acuity must be within normal range.

4. Must be able to communicate effectively.

5. Must have manual dexterity to operate keyboard, fax machines, telephones and other business equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office work which includes sitting for extended periods of time.

2. Maintains confidential home office space

3. Required weekends and holidays as assigned

SKILLS & ABILILTIES

1. Effective verbal and written communication skills.

2. Strong interpersonal skills.

3. Strong attention to detail.

4. Knowledge of medical terminology required.

5. Knowledge of third party payers required.

6. Ability to use tact and diplomacy in dealing with others.

7. Working knowledge of computers.

8. Excellent customer service and telephone etiquette

SYSTEM West Virginia University Health System Cost Center

553 SYSTEM Utilization Review Originally posted on Himalayas