RN Utilization Review

The Utilization Review RN performs activities which support the Utilization Management functions. They are responsible for the delivery of the Utilization Management process including but not limited to making clinical recommendations regarding medical necessity for admission and continues stay, screens patients for client specific guidelines regarding insurance, Medicare and/or Medicaid guidelines, send payor specific Notice of Admission and continued stay reviews. “Performs utilization review activities under established criteria, policies, and UM leadership oversight. The employee communicates with physician and case managers regarding payor approval/denial of admission and continue stay review. They process payor denials and retro reviews, promote optimal health care outcomes in accordance with the policies, procedures, applicable laws and contracts, philosophy, mission and values of UofL Health, assumes responsibility and accountability for the appropriate utilization of facilities and services and serves as a resource to physicians. The employee conducts admission and concurrent reviews including observation and inpatients, identifies patients who do not meet criteria and takes action to ensure patients are cared for in the most appropriate level of care; coordinates care in conjunction with other members of the interdisciplinary healthcare team to provide and facilitate optimal health and financial accountability. This employee utilizes the nursing process (assess, plan, implement and evaluate) and management process (plan, organize, direct and control) to provide a framework for decision-making; maintains confidentiality of information; actively supports organizational goals and objectives by providing needed information to divisions and departments. Participates in ongoing UM competency validation and regulatory education. Essential Functions:

Promotes optimal management of clinical resources by conducting timely admission and concurrent utilization review for all patients of designated medical services; certifies medical necessity for admission, continued stay and discharge reviews for patients certified by utilizing the current MCG criteria; documents clinical information in Case Management Software system

During the concurrent review process, evaluates the medical record to identify any process delay impacting the timeliness of patient care in a collaborative effort to ensure that the appropriate resources are utilized (i.e. physical therapy, cardiac rehabilitation, or nutritional service)

Supports the utilization review program by maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers

Communicates closely with third party payors to ensure all pertinent clinical information is provided to secure an authorization; appropriately documents information regarding the authorization number and the approved length of stay on the Case Manager Software

Advocates for patient/family needs in a respectful, non-judgmental, and confidential manner

Serves as a resource to physicians for clinical management and financial issues; assists the providers with promoting efficiencies in the care delivery system and reducing/ eliminating barriers to efficient/effective service

Reviews patient cases for potential problems with OIG Workplan Audits and compliance issues; reports problems and makes recommendation to appropriate departments

Appropriately refers cases to manager/director of care coordination, CAO, or medical director when intensity of service or severity of illness is not present and is unable to resolved

Educates physicians, patients, and staff with regards to payors, financial issues, documentation, and potential compliance issues

Investigates and responds to billing concerns from Business Office, Health Information Management, Admitting, and other sources; resolves financial and billing problems, such as appropriate patient status, correct payor source, denials, appeals, and system issues

Develops a cooperative, assistive relationship with third-party reviewers, working to facilitate timely, positive responses for patient accounts

Attends Monthly Departmental Staff Communications Meetings. Serves as an active member of committees, as needed, which may include a variety of projects or topics

Enhances professional growth and development through participation in educational programs, reading current literature, attending in-service meetings and workshops that are related to assigned areas of responsibility.

Maintains compliance with all company policies, procedures and standards of conduct

Complies with HIPAA privacy and security requirements to always maintain confidentiality

Performs other duties as assigned Additional

Job Requirements (Education, Experience, Licensure and Certification) Education:

• ADN or
• Associate’s degree in nursing (Required)
• Bachelor of Science in Nursing (preferred) o An RN with a bachelor's degree in business, Health Care Administration or equivalent on the condition that they enroll in a BSN program within one year of employment and complete the BSN within three years of employment Experience:
• Two (2) years’ experience as an RN (required)
• Additional (1) year experience in case management/utilization management (preferred)
• Three years’ experience with Behavior Health experience (required for positions at Peace Hospital) Licensure:
• Active Kentucky Registered Nurse License or compact license with privileges to work in Kentucky Certification:
• Case Management Certification (ACM, ANCC-Nurse Case Manager or CCM) preferred Job Competency: Knowledge, Skills, and Abilities critical to this role:
• Must be able to adjust priorities quickly, organize multiple tasks simultaneously, and work interdependently with many levels of staff
• Attention to detail; strong organizational, interpersonal and communication skills; and innovative problem-solving skills required
• Assumes responsibility of person growth and development, maintains competency in care management/utilization management principles
• Maintains current and accurate knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to utilization review
• Knowledgeable of state laws, CMS conditions of participation, and TJC standards regarding regulatory requirements for care management and utilization management
• Knowledgeable of the services lines and uses sound nursing judgement and adheres to the code of professional conduct.
• Understands and can exhibit RN licensure scope of practice
• Must be able to adjust work hours depending upon departmental and organizational needs as determined by the director or manager of care coordination or the CNO
• Functions within RN scope of practice and UM policies; adhere to CMS Conditions of Participation and Payer requirements. Language Ability:
• Must be able to communicate effectively in both verbal and written formats Reasoning Ability:
• Able to critically think through complex patient situations, process improvements, evidence-based practice