The Utilization Review nurse works with the multidisciplinary team including physicians, staff and payers to ensure patient's progress along the continuum of care in an efficient and cost-effective manner that ensures quality outcomes. They utilize established guidelines to support appropriate level of care throughout hospitalization. They serve as a liaison between the hospital and external payers on issues related to severity of illness and intensity of service for patients to ensure appropriate and timely utilization of hospital services. The position includes but not limited to basic UR job duties such as level of care determination, clinical submission to payers, timely following/securing of auth payer status, timely discharge notification, monitoring status of procedural cases and submitting/monitoring post acute authorization status.
Admission and Concurrent Case Review
Uses approved criteria for admission and continued stay reviews to ensure appropriate setting and timely implementation of plan of care.
Monitors patient's progress across the continuum and intervenes as necessary to ensure quality services that are efficient and cost effective.
Collaborates with admitting physician regarding appropriate level of care/status determination.
Consults with Physician Advisor and administrative leadership as necessary for those patients not meeting medical necessary services for acute care.
Knowledgeable of Medicare, Medicaid and non-governmental payer regulations for patient care requirements.
Responds to requested insurance reviews based on contractual obligations.
Actively manages concurrent denials.
Reports data per request of the appropriate leadership for information and resolution, which may include risk management, epidemiology, payer requirements, and performance improvement departments.
Complete timely discharges and final authorization status to ensure alignment of payer auth and claim submission.
Regulatory and Contractual Compliance
Demonstrates service excellence by providing complete clinical information to government and non-governmental review organizations following HIPAA guidelines.
Identify and document appropriate necessary changes in level of care.
Partners with Case Management for Medicare patients disputing their discharge.
Delivery of Detailed Notice of Discharge and transmission of medical records to the QIO within required timeframes.
Partners with Case Management for delivery of any regulatory documentation.
Documents all pertinent communication regarding certification in clinical database.
Timely submission of all initial, concurrent and discharge reviews.
Serves as a resource to the healthcare team regarding utilization standards and potential alternatives to acute care hospitalization.
Evaluate hospitalized patients to make sure they are receiving services in the most appropriate and cost - effective setting in collaboration with attending physicians.
Additional responsibilities as needed.
