Utilization Review Care Manager, RN

Overview

Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, medical necessity standards, and/or and InterQual guidelines.  The Utilization Review Nurse utilizes clinical knowledge to support the coordination and documentation and communication of medical services and/or benefits. The Utilization Nurse also serves on the liaison between the physicians, patients, payers and care managers regarding termination of benefits, denial notification, and expedited appeals. Has access to highly sensitive, confidential information.

Responsibilities

Evaluates medical records for appropriateness of admission status utilizing a combination of clinical information, screening criteria, and third party information. Collaborates with business office, care managers, attending physicians, and physician advisors as needed.

Works with Patient Registration\Financial Counselor (s) to identify correct insurance source and proper billing.

Verifies patient admission information for each assigned patient within 24 hours of patient’s admission (next business day) or per payer guidelines.

Collaborates with the Case Manager to identify referrals to Financial Counselors.

Negotiates resolution of disagreements over the need for acute hospital level of care with the insurer.

Educates staff and physicians about managed care principles, observation status, and reimbursement rules.

Maintains records in a complete, detailed, and orderly manner.

Identifies Potential Avoidable Days per department policy.

Conducts self-auditing of medical records for status accuracy and provides peer consultation regarding cases in which patients are failing to progress and/or experiencing significant deviation from the plan of care.

Collaborates with case managers and social workers for patients with complex, clinical, financial and psycho-social needs.

Reviews physician orders and patient progression and intervenes with care coordination as needed. Collaborates with other departments to eliminate barriers, as necessary.

Builds trusting relationships with attending physician, patient and/or family and other members of the healthcare team. Establishes a caring relationship with patients and their caregivers, promotes patient engagement and guides patients/families through the transition phase

Gathers information for statistical monitors, plus special projects within the Care Management Department.

Updates and documents in Expanse and Cortex, pertinent clinical information by utilizing screening criteria and assigns next review date.

Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS) and reduction of avoidable readmissions.

Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians.

Identifies and reports Quality and Risk Management concerns and enters risk events in Midas.

Is knowledgeable of hospital mission, vision, and values and performs in a manner to support them.

Reviews an average of 25 patients per day.

Delivers denial letters from all payers to the beneficiary or proper representative; explain appeal rights.

Must be able to successfully complete the Interrater Reliability Tool for InterQual Level of Care Acute Criteria. (Adult and Pediatric) after successful orientation.

 

DCH Standards

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Requires use of electronic mail, time and attendance software, learning management software, and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Qualifications

• Anyone hired after July, 2011 must meet the following:
• Minimum of Registered Nurse with current Alabama license.
• Minimum 2 years experience as an RN preferred.
• Minimum of at least 2 years as care management and/or utilization management experience preferred.
• Minimum of 2 years of Med Surgical experience preferred; Utilization Review experience preferred.
• Expected to work under minimal management supervision
• Efficient use of basic computer skills
• Ability to multi task, prioritize and effectively adapt to a fast paced changing environment
• Sedentary work involving periods of sitting, talking, and listening. Work requires sitting for extended periods, talking on the phone, and typing on the computer.
• Work requires the ability to perform close inspection of computer generated documents as well as a PC monitor.
• Typical office working environment with productivity and quality expectations.
• Ability to establish priorities, meet deadlines, and maintain proper productivity.
• Ability to form positive, collaborative relationships with hospital staff, patients, families, and payers.
• Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.
• Ability to effectively negotiate with internal and external providers of patient care services.
• Ability to develop leadership skills and to serve as a role model for clinical staff.
• Ability to actively participate in multidisciplinary teams.
• Ability to work independently or within a team structure.
• Excellent interpersonal skills, communication style, and organization.
• Must be able to read, write legibly, speak, and comprehend English.

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals

 

PHYSICAL FACTORS

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.

• Ability to tolerate prolonged periods of sitting or standing and/or walking.
• Ability to reach reasonable distances to handle equipment.
• Good manual and finger dexterity.
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.