RN Utilization Review Full-time
Conway Regional Health System

Case Manager / Utilization Review Nurse

Conway Regional Health System Conway, AR 72034, US
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Overview

Provides discharge planning and utilization review services in compliance with patient’s discharge planning needs and the hospital’s utilization review program. 

 

SAFETY SENSITIVE POSITION:

 

This position is a designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers which Conway Regional is responsible for in providing and supporting the delivery health care related services.

 


Responsibilities

  • Demonstrates initiative and pursues activities which contribute to the accomplishment of goals and objectives
  • Appropriately utilizes organizational resources to achieve the goals and objectives
  • Considers cost implications in all decision making
  • Promotes efficiency enhancements; actively identifies and implements cost savings/containment initiatives
  • Apply clinical knowledge to determine appropriate acuity levels and utilization through chart review
  • Effectively organizes workflow to consistently complete assignments in a timely manner
  • Demonstrates ability to access and effectively utilize primary sources of data
  • Obtains and maintains medical records in conformance with Medical Information policies
  • Communicates with co-workers in a manner that is conducive to positive and effective working relationships. Demonstrates respect, honesty and integrity when working with other service providers
  • Demonstrates compliance with all relevant hospital, state and federal requirements related to maintenance of confidentiality of persons, data and information systems
  • Takes advantage of opportunities made available through CRHS and other professional organizations for continued professional growth and development
  • Responsible for analysis of patient information for determination of necessity of admission or continuation of stay
  • Review for medical necessity of admission on the first working day after admission using approved review criteria
  • Reviews inpatient procedures to determine appropriate utilization and acuity level. Reviews potential for outpatient setting or swing bed utilization
  • Reviews all patients for medical necessity of continued stay, or before the next review date, using approved review criteria
  • Performs retroactive reviews, as necessary, and responds to the appropriate review agency or third-party payor
  • Researches denials issued by review agencies and third-party payors and responds within the specified time frames for appeal
  • Works with others on healthcare team to coordinate for patients discharge needs
  • Establishes an effective utilization review process and maintains an active, effective utilization review file system. Recommends, develops and revises policies related to the utilization review process
  • Works collaboratively with physicians, Case Management, the discharge planning process, Admissions, Central Scheduling and other CRHS associates
  • Educates staff, physicians and other personnel regarding medical necessity requirements as defined by approved review criteria
  • Attends 75% of staff meetings
  • Participates in committees which promote staff and medical center facility growth as directed by Director/Manager and/or CRMC policy
  • Attends mandatory in-services and committee meetings as assigned
  • Adheres to dress code, conduct and attendance policies
  • Participate in activities that promote personal development
  • Must maintain all organizational education and work requirements (i.e., Annual Mandatory Education, Competencies, BLS Provider, etc.)
  • Other duties as assigned by management

Qualifications

    • Registered Nurse or Licensed Practical Nurse with current, active license to practice in Arkansas, required
    • Proof of the highest level of nursing education achieved, required
    • At least one-year experience in the area of case management/utilization review, preferred

     

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