Utilization Review Nurse

Job Description

Job Description

Utilization Review Nurse

Full-Time - 8A to 4P

WHO WE ARE:
In 2004, in an ambitious push to bring hospitality back to the hospital, a small group of top Metro-Detroit surgeons decided to create their own surgical hospital; one that provided patients with the best possible care in a small, easy-to-manage environment that truly embraces the best patient experience. Our highly skilled surgeons and staff play a key role in our success rates and becoming the premier center of choice with 30 surgical beds and 6 operating rooms.

WHAT WE ARE LOOKING FOR:

Role/Position Definition: The Utilization Review (UR) Nurse provides healthcare services regarding admissions, case management, and utilization review to facilitate discharge planning and care coordination for cost-effective quality healthcare. The UR Nurse has the overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge, and prevent avoidable readmissions. The UR Nurse integrates national standards for case management scope of services including: Utilization Management supporting medical necessity and denial prevention. Transition Management promoting appropriate length of stay, readmission prevention, and patient satisfaction. Care Coordination by demonstrating throughput efficiency while assuring care is in the right sequence and appropriate level. Compliance with state and federal regulatory requirement, HFAP accreditation standards, and organization policy.

Qualifications/Position Requirements:

1. Education/Experience

• Associates degree from an accredited school of nursing required, Bachelor’s degree in Nursing preferred.
• 3+ years of case management/UR experience preferred.

1. Licensure/Certification

• Current unrestricted RN License from the State of Michigan required.

3. Knowledge, Skills and Abilities

• Excellent customer services skills necessary in order to deal effectively with various levels of organization personnel, outside customers, and groups.
• Ability to work autonomously with little direction and be accountable for outcomes.
• Must possess excellent written and verbal communication skills.
• Ability to exercise professional judgment and initiative when analyzing problems and
• recommending solutions.
• Knowledge of InterQual criteria, government agencies, insurance benefits coverage and DRG/PDPM payment systems.
• Hospital medical case management/discharge planning experience.
• Proficient computer skills, including use of Microsoft Office software (Outlook, word and excel)
• Understanding of Electronic Health Records preferred

4. Duties and Responsibilities:

• Reviews the medical records of all observation, surgical and medical admissions to determine the medical necessity for admission and continued stay, daily.
• Reviews all requests for elective medical admissions for appropriate utilization and necessary patient-care planning prior to admission.
• Reviews all requests for elective surgical procedures scheduled to ensure appropriate utilization.
• Obtains inpatient authorization for surgical patients requiring inpatient stay.
• Reviews inpatient census, daily, for admission and observation status, and facilitates any updates, as needed.
• Responsible for preparing UR reports and documents for the Utilization Review Committee. Attends and participates in the UR Committee along with all other committees as directed (i.e., QA, Safety, Nursing).
• Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement, and claim denials/appeals.
• Works with staff (physicians, nursing, and patient access) to ensure correct observation/admission orders are written.
• Continues review of all patients using criteria and determines need for continued hospitalization based upon third-party payer/insurance guidelines.
• Based on third party payers/insurance guidelines, communicates as required for continued stay review. May include phone, fax, and payer website (i.e. WebDenis).
• Working knowledge of severity of illness and intensity of service factors that determine alternative levels of care.
• Collaborates with QAPI Department: Performs quality assessment reviews and studies both concurrently and retrospectively as required by the hospital’s QAPI plan, HFAP standards, and third-party payer regulations.
• Advocates for the patient and hospital with third-party payers to secure appropriate payment for services rendered.
• Prevents denials and disputes by communicating with third-party payers and documenting relevant information. Files for inpatient and observation appeals as a result of third-party payer denial or obtaining authorization.
• Establishes and maintains effective communication with all referral sources, insurers, vendors, and patient supplier systems.
• Interacts, communicates, and intervenes with multidisciplinary healthcare team in a purposeful, goal-directed fashion. Works proactively to maximize the effectiveness of resource utilization. Anticipates, initiates, and facilitates problem resolution around issues of resource use and continued hospitalization and discharge planning.
• Identifies and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes communicating information through clear, complete, and concise documentation.
• Consistently maintains a professional commitment to institutions and department’s goals and objectives. Demonstrates flexibility to the department’s needs in relation to floor and work schedule and any other internal and external demands on the department. Continually shows commitment to the department by extending one’s self when the need arises.
• Assists in reviewing incoming patient referrals, as needed, utilizing InterQual criteria set for admission into rehabilitation units (Sub-acute and Medical).
• Maintains current knowledge of case management, utilization management, and discharge planning, as specified by federal, state, and private insurance guidelines.
• Provides applicable patients with Code 44 form prior to discharge when a physician orders an inpatient admission, and the level of care does not meet admission criteria, the hospital may change the status to outpatient only.
• Provides applicable patients with an official Medicare Outpatient Observation Notice (MOON) form. Under the NOTICE Act, every patient who receives observation services as an outpatient for more than 24 hours must receive an official MOON form. The MOON is a standardized form created by the Centers for Medicare & Medicaid Services (CMS)
• Assist with arranging post-discharge services, if necessary.
• Communicate with the clinical staff as needed for clarification of the patient’s status and update them on the discharge plan.
• Provides documentation in a legible manner to maintain the quality of the medical record as it relates to reimbursement guidelines, accuracy, and facility requirements.
• Participates in meetings, as necessary.
• Performs all other duties as assigned.

OUR COMMITMENT TO OUR STAFF:

• Health Safety Measures in place for everyone
• A diverse & inclusive workforce that embraces communication, caring and courtesy
• Positive onboarding experience
• Health Insurance plans effective 1st of the month following 30 days
• Company-paid life insurance
• Supplemental Life and Disability insurance plans
• Generous PTO accrual at start of employment
• Tuition Reimbursement & Continuing Education opportunities
• 401k with company match
• Company Events
• Community discounts
• And more!