RN Utilization Review Coordinator, Full-time

About the role

The RN Case Manager/Utilization Review is responsible for performing prospective, concurrent, and post-discharge utilization reviews to ensure appropriate patient status, medical necessity, and compliance with hospital policy, payer requirements, and applicable local, state and federal regulations, including Centers for Medicare & Medicaid Services (CMS) guidelines.

Responsibilities

• Conduct comprehensive medical record reviews using specific criteria and guidelines as approved and/or established by medical staff, CMS, and other state and federal agencies while ensuring physician and nurse documentation meets set standards.
• Perform prospective (pre-admission and pre-operative), concurrent, and post-discharge utilization reviews to verify medical necessity and appropriate level of care throughout the episode of care using the hospital-approved criteria software.
• Screen and determine appropriate admission status (inpatient, observation, outpatient, or outpatient in a bed) based on clinical documentation, hospital-approved medical-necessity guidelines, and payer requirements.
• Facilitate appropriate admission status determinations based on clinical documentation and payer requirements.
• Review clinical documentation for accuracy, completeness, and compliance with regulatory and payer standards.
• Collaborate with physicians and nursing staff to ensure timely, accurate orders and documentation supporting medical necessity.
• Communicate with physicians when cases do not meet admission or continued stay criteria and assist with resolution.
• Submit timely admission, continued stay, and discharge notification and appropriate clinicals to insurance companies as required.
• Complete admission status changes as needed in the hospital computer system.
• Identify, track, and manage utilization review denials related to admission status, level of care, length of stay, and medical necessity.
• Draft, write, and submit denial appeal letters using clinical judgment, medical record review, applicable payer, CMS, and regulatory guidelines to support medical necessity determinations.
• Collaborate with physicians, case managers, physician advisors, and leadership to obtain supporting clinical documentation, physician statements, and peer-to-peer review input for appeals to support denial resolution.
• Maintain accurate documentation of denials and appeals in accordance with hospital policy and regulatory requirements.
• Support and enhance collaborative relationships with the healthcare team, physicians, patients, and families to maximize the patient’s and family’s ability to make informed healthcare decisions.
• Avoidable days and extended lengths of stay; identify contributing factors related to utilization, payer processes, discharge barriers, and system delays, and collaborate with Case Management, physicians, and interdisciplinary teams to support timely resolution.
• Assist the Case Management Manager and Quality Director with data collection and analysis for quarterly and annual utilization review reports.
• Investigate and report adverse occurrences and trends related to utilization, discharge planning, or resource management.
• Provide staff education related to utilization review processes, medical necessity, and resource utilization.

Requirements

• Education: Bachelor of Science in Nursing preferred.
• Certification, Licensure: Active RN license in Texas; current CPR certification.
• Case Management Certification(s) preferred.
• Experience, Training, Knowledge: At least five years of experience with Case Management, Discharge Planning, and Utilization Review.