nThrive

Utilization Review RN

Job ID
2017-20843
Employment Type
part-time
Naples
Hours Per Week
0.00
FL

Overview

The UR Nurse monitor’s adherence to Hospital’s Utilization Review Plan to ensure the effective and efficient use of hospital services. Assists physicians and mid-level providers in the determination of the appropriate level of care assignment both at the time of initial placement in the hospital and as the patient’s clinical condition evolves. Monitors the appropriateness of hospital admissions and extended hospital stays.

Responsibilities

  • Reviews medical records for appropriate application of medical necessity criteria to determine the appropriateness of admission and/or continued stay and readiness for discharge using InterQual criteria and clinical expertise.
  • Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Communicates patient admission status information to business operations staff in a timely manner such that patients obtain timely and appropriate care in the hospital setting as required by their clinical conditions.
  • Performs concurrent clinical review for patients to ensure that extended stays are medically justified and are so documented in patient's medical. Communicates with attending physician regarding patients clinical condition, signs and symptoms as needed to ensure the patient’s admission status is supported by the physician’s documentation consistent with industry accepted guidelines and payer rules/regulations.
  • Works in conjunction with Clinical Documentation Improvement nurses to identify the Working DRG for patients admitted as inpatients and ensure the Working DRG is entered into the Cerner UM Module in order to calculate the GMLOS.
  • Enters clinical reviews into the UM Module within Cerner and works with the Utilization Review Coordinators to ensure necessary concurrent clinical information is transmitted to third-party payers and required by the payer and/or any payment contract with facility.
  • Ensures prior authorizations are entered into the UM Module for those services requiring prior authorization from the patient’s third-party payer. Enters approved hospital days into the UM Module when received by the patient’s payer.
  • Participates in daily departmental planning meetings and meets with the clinical team to guide the patient’s discharge plan.
  • Assure the RN Care Coordinator assigned to the patient is aware of the self-pay status of patients and make necessary referrals to financial counselors and/or hospital’s contracted financial counseling agencies, members of the healthcare team regarding target length of stay (LOS), acute care criteria, pay requirements, resource utilization, and care options to meet patient needs.
  • Develops and maintains relationships with third-party payers necessary to coordinate the appropriate utilization of hospital resources and meet the clinical needs of assigned patients.
  • Refers to the Utilization Review Physician Advisor all cases that do not meet established guidelines for admission or continued stay consistent with the arrangement with the Physician Advisor.
  • Performs concurrent review of acute and sub-acute services, as well as precertification review for all services following the plans authorization guidelines.
  • Predicts and plans for patient’s needs from admission through acute and sub-acute care and post-discharge, in collaboration with the patient’s third-party payer and providers.
  • Acts as a liaison with the RN Care Coordinators and Care Coordination Social Workers to facilitate the appropriate utilization of hospital resources and timely discharge. Tracks and reports trends of inappropriate utilization of resources to the Utilization Review Manager.
  • Participates in a regular rotation of weekend and after-hours coverage in order to meet Department needs as determined by the Director of Case Management.

Qualifications

  • Licensed as a Registered Nurse.
  • Certification in clinical case management or utilization review strongly desired.
  • Bachelor’s degree in Nursing (BSN) or Associate’s degree in Nursing (ASN) with Bachelor’s degree in a closely related field required.
  • Minimum of 3 years nursing experience prior to care coordination required.
  • Knowledge of Medicare and Medicaid payment rules, policies and regulations.
  • Strong written and verbal communication skills.
  • Ability to effectively use MS Word and Outlook required.
  • Ability to evaluate medical records and other health care data.
  • Ability to exercise good judgment and tact in relating to third-party payers, physicians and patients.
  • Ability to establish and maintain effective and cooperative working relationships with Hospital staff and others contacted in the course of this position.
  • Ability to work as a part of a team.
  • Ability to accurately complete tasks within established times.
  • Demonstrated ability to effectively prioritize multiple tasks and deadlines and work independently.
  • Ability to maintain confidentiality in all tasks performed.
  • Excellent problem solving skills.
  • Demonstrated ability to effectively present information and respond to questions from small groups or on a one-on-one basis.
  • Demonstrated ability to deal with problems involving several concrete variables in standardized situations.

Preferred Skills

  • At least 5 years nursing experience prior to care coordination preferred.

About nThrive

nThrive is the leader in providing end-to-end revenue cycle services, technology and education solutions. Previously known as MedAssets, Precyse, Equation and Adreima, each formerly a leader in its own right, we’ve combined our talents and capabilities into a single enterprise. At nThrive, we are people who are passionate about empowering health care for every one in every community. We work together to transform financial and operational performance, enabling health care organizations to thrive.
 
nThrive is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity or any other federal, state or local protected class.

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