Utilization Review Nurse; On-Call, Maui Health

Coordinates with physicians, staff, and non-Kaiser providers and facilities regarding patient care. In conjunction with physicians, develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, identifies cost-effective protocols, and develops guidelines for care.

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• Performs daily pre-admission, admission, and concurrent utilization reviews to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved immediately. Performs rounds and reviews patient admissions under Kaiser Skilled Nursing Facility (SNF) benefit. Utilizes knowledge and experience of Medicare regulations and Health Plan benefits to determine medical necessity. Monitors the progression of the plan of care and facilitates discussions with the multidisciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives.  Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Issues denial/notices of non-coverage letters after conferring with physicians.
  
• Ensures continuity of care for outside services for the patient. Monitors level of care. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies.
  
• Monitors care processes and participates in the development and implementation of guidelines, pre-printed physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Establishes and maintains effective relationships between Kaiser Permanente and the community facilities. Identifies quality improvement and relationship building opportunities. Monitors high-cost cases and reports findings to Hospital Administration, Director of Continuing Care and/or Community Medical Services. Keeps abreast of current changes in health care benefits, laws or regulatory requirements which influence health plan benefit issues.
  
• May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
  
• Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
  
• Incorporates the KP Nursing Vision, Model and Values throughout their Nursing Practice.