RN-Utilization Review (Remote Position - AZ Residents ONLY!)
Kingman Regional Medical Center · Kingman, AZ · 1 mo ago
HealthcareFull-time
We need to output HTML fragment with sections: About the role? The description includes Position Purpose, Key Responsibilities, Qualifications, etc. We need to use for section headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We must only include sections when posting has real specific content. No Pay, Schedule, Benefits unless present. The posting does not mention pay, schedule, benefits. So we should not include those headings. We need sections: About the role (maybe from Position Purpose), Responsibilities (Key Responsibilities), Qualifications (Education, Experience, Licensure, Certification), Skills (Knowledge, Skills, And Abilities), maybe Additional Duties? Could be part of Responsibilities. Also maybe "Exposure Categories" etc. But we should follow headings list: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We can map content: About the role = Position Purpose + maybe general description. Responsibilities = Key Responsibilities + Additional Duties? Requirements could be licensure? But we have Qualifications separate. Could combine Requirements as licensure etc. However we must not repeat headings with filler. We need to decide which sections to include based on content.
We have content: Position Purpose, Key Responsibilities, Qualifications (Education, Experience, Licensure, Certification), Knowledge, Skills, And Abilities, Additional Duties, Exposure Categories, Work Requirements, Acknowledgement (boilerplate to drop). Also Safety Sensitive etc metadata (drop). Also Position Code etc (drop). Also Reports to etc (drop). Also Exempt Status etc (drop). Also Acknowledgement etc (drop). Also "Special Position Requirements" maybe part of Qualifications? We'll include relevant.
We need to avoid boilerplate like EEO etc. Not present.
We need to preserve all substantive info. So we need to include all details from Position Purpose, Key Responsibilities, Qualifications, Knowledge Skills And Abilities, Additional Duties, Exposure Categories, Work Requirements.
We must not invent or summarize away detail. So we need to keep specifics like "Conducting and coordinating medical necessity reviews for all patients upon admission to inpatient or observation status and complete continued stay reviews throughout the stay." etc.
We need to format lists with
for section headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We must only include sections when posting has real specific content. No Pay, Schedule, Benefits unless present. The posting does not mention pay, schedule, benefits. So we should not include those headings. We need sections: About the role (maybe from Position Purpose), Responsibilities (Key Responsibilities), Qualifications (Education, Experience, Licensure, Certification), Skills (Knowledge, Skills, And Abilities), maybe Additional Duties? Could be part of Responsibilities. Also maybe "Exposure Categories" etc. But we should follow headings list: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We can map content: About the role = Position Purpose + maybe general description. Responsibilities = Key Responsibilities + Additional Duties? Requirements could be licensure? But we have Qualifications separate. Could combine Requirements as licensure etc. However we must not repeat headings with filler. We need to decide which sections to include based on content.
We have content: Position Purpose, Key Responsibilities, Qualifications (Education, Experience, Licensure, Certification), Knowledge, Skills, And Abilities, Additional Duties, Exposure Categories, Work Requirements, Acknowledgement (boilerplate to drop). Also Safety Sensitive etc metadata (drop). Also Position Code etc (drop). Also Reports to etc (drop). Also Exempt Status etc (drop). Also Acknowledgement etc (drop). Also "Special Position Requirements" maybe part of Qualifications? We'll include relevant.
We need to avoid boilerplate like EEO etc. Not present.
We need to preserve all substantive info. So we need to include all details from Position Purpose, Key Responsibilities, Qualifications, Knowledge Skills And Abilities, Additional Duties, Exposure Categories, Work Requirements.
We must not invent or summarize away detail. So we need to keep specifics like "Conducting and coordinating medical necessity reviews for all patients upon admission to inpatient or observation status and complete continued stay reviews throughout the stay." etc.
We need to format lists with - for any list of duties/requirements/benefits. So for responsibilities we can list each duty as
- . For qualifications we can list education, experience, licensure, certification as list items. For skills we can list each ability as
- . For exposure categories and work requirements maybe also list.
We need to decide headings: About the role (Position Purpose). Responsibilities (Key Responsibilities + Additional Duties). Qualifications (Education, Experience, Licensure, Certification). Skills (Knowledge, Skills, And Abilities). Maybe also "Requirements" could be licensure? But we already have Qualifications. Could omit Requirements heading if no distinct content. The instruction: "Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It's examples, not mandatory to use all. We should include only those with real content. So we can include About the role, Responsibilities, Qualifications, Skills. Possibly also Requirements if we have licensure etc separate from Qualifications? But we can treat licensure as part of Qualifications. So we skip Requirements.
We must not repeat job title as heading. Already not.
We must not include Pay/Schedule/Benefits sections.
We must output only HTML fragment.
Let's craft:
About the role
All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision to be among the kindest, highest quality health systems in the country.
Responsibilities
- Conducting and coordinating medical necessity reviews for all patients upon admission to inpatient or observation status and completing continued stay reviews throughout the stay.
- Evaluating surgical schedule for inpatient only procedures (IPOs) and communicating via message system the need for appropriate orders.
- Verifying physician orders in the medical record follow Medicare and other payer guidelines for determining level of care.
- Assuring medical documentation accurately reflects the severity of illness and acuity of the patient.
- Communicating with KHI medical staff as needed to reconcile and clarify admit orders and/or medical documentation to ensure that the hospital is reimbursed appropriately for services rendered.
- Consulting with Physician Advisor as needed to make medical necessity determinations and/or make referrals for cases not meeting criteria as per KHI Utilization Management Plan.
- Working collaboratively with Case Managers and Insurance Specialist to ensure that appropriate and accurate clinical information is communicated to payers within required timeframes as per KHI policies and procedures.
- Ensuring complete, accurate and timely entry of information related to the utilization review process into data systems.
- Maintaining documentation of all activities to support medical necessity determinations.
- Collaborating with all members of the healthcare team, the business office, and payers as necessary, to ensure patients receive high quality care in the most cost-effective manner.
- Collaborating with Denials Manager and RAC team to identify issues and/or trends related to medical necessity denials and participating in the denials management process.
- Serving as a resource to Case Management staff and providing education and coaching regarding appropriate use of clinical guidelines, utilization review and payer regulations.
- Establishing communications system for days off.
- Assisting in sending admitting and discharge clinicals on all patients.
- Reviewing Medical Records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria.
- Evaluating medical information against nationally recognized criteria and determining necessity for admission, continued stay, appropriateness of service, and/or level of care.
- Collaborating with physicians to determine appropriate inpatient versus observation status and ensure appropriate documentation and appropriate orders are entered.
- Performing Code 44 when needed and communicating downgrades to appropriate staff.
- Notifying Admitting, Insurance verifiers, and Apogee regarding status change of admission via email.
- Determining which cases will require medical staff review intervention and/or UR management intervention, considering factors such as appropriateness, quality, etc., during the Case Management process.
- Communicating with the attending physician, expected length of stay, Medicare guidelines and individual variances.
- Collaborating with the Case Managers and Insurance Specialist to ensure appropriate documentation, awareness of potential denials, and any needs of clarification within the EMR from physician.
- Assisting in educating Case Managers, Social Workers, and Physicians on changes in CMS guidelines, documentation requirements, etc.
- Protecting patients’ rights as they pertain to the ethical and legal issues of confidentiality during the case management process.
- Participating in committees, performance improvement activities, mandatory in-services, and continuing education.
- Maintaining compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines.
- Performing additional duties as requested, such as focused studies, appeal letters, outlier reporting, patient satisfaction initiatives, etc.
Qualifications
- Education: Graduate from an accredited school of nursing.
- Experience: Minimum of three years clinical experience as an RN preferably in a hospital medical surgical or critical care setting; minimum one year of utilization review experience or two years case management experience as an RN.
- Licensure: Current, valid Arizona or compact state RN license.
- Certification: N/A (preferred: BSN or MSN; CCM or ACM – will allow time to obtain).
Skills
- Strong clinical skills and knowledge, and the ability to recognize when quality issues exist.
- Knowledge of nationally recognized criteria used to make medical necessity determinations; experience using Milliman or InterQual criteria preferred.
- Strong interpersonal, organizational, and motivational skills, as well as proficiency in written and verbal communication.
- Effective problem‑solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
- Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open‑minded, and adaptable to change.
- Good assessment skills and knowledge of clinical and social factors that may affect the patient’s functional status at discharge.
We might also include Exposure Categories and Work Requirements under Skills or maybe as separate sections? But we only have allowed headings list; we could add them under Skills as additional items. However they are not skills but requirements. Could include them under Qualifications? But we already have qualifications. Could add a separate section "Requirements" for exposure categories and work requirements. The instruction says we can use Requirements heading. So we could add a Requirements section for Exposure Categories and Work Requirements. That would be appropriate.
Thus we add:
Requirements
- Exposure Categories: Special Position Requirements Blood Borne Disease Exposure Category II; other potential hazard(s): Volatile/violent patients or family members.
- Work Requirements: Able to handle multiple priorities simultaneously; able to manage technical business equipment i.e., phone, fax, computer etc.; ability to sit for 5‑8 hours per day; ability to stand for 3‑5 hours per day; ability to walk for 3‑5 hours per day.
We must ensure we don't include boilerplate like "Acknowledgement". Already omitted.
Now ensure we didn't repeat job title as heading. Good.
Check for any repeated content: We included all responsibilities etc. Ensure we didn't miss any: The original had "Reviews Medical Records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria." included. "Evaluates medical information against nationally recognized criteria and determines necessity for admission, continued stay, appropriateness of service, and/ or level of care." included. "Collaborates with the physicians to determine appropriate inpatient versus observation status and ensure appropriate documentation, and appropriate orders are entered." included. "Perform Code 44 when needed and communicates downgrades to appropriate staff." included. "Notifies Admitting, Insurance verifiers, and Apogee regarding status change of admission via email." included. "Utilization Determines which cases will require medical staff review intervention and/or UR management intervention. Factors such as appropriateness, quality, etc., are taken into consideration during the Case Management process." included. "Communicates with the attending physician, expected length of stay, Medicare guidelines and individual variances." included. "Collaborates with the Case Managers and Insurance Specialist to ensure appropriate documentation, awareness of potential denials, and any needs of clarification within the EMR from physician." included. "Assists in educating Case Managers, Social Workers, and Physicians, changes in CMS guidelines, documentation requirements, etc." included. "Quality of Care: Protects patients’ rights as they pertain to the ethical and legal issues of confidentiality during the case management process." included. "Compliance Participates in committees, performance improvement activities, mandatory in-services, and continuing education. Maintain compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines." included. "Additional Duties: Perform additional duties, as requested, such as: focused studies, appeal letters, outlier reporting, patient satisfaction initiatives, etc." included.
Qualifications: Education, Experience, Licensure, Certification. We included N/A but also note preferences: BSN or MSN; CCM or ACM (will allow time to obtain). We included as note.
Skills: we included all from Knowledge, Skills, And Abilities.
Requirements: Exposure Categories and Work Requirements.
Check for any leftover substantive info: "Safety Sensitive: ☒ Yes ☐ No" is metadata,
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It's examples, not mandatory to use all. We should include only those with real content. So we can include About the role, Responsibilities, Qualifications, Skills. Possibly also Requirements if we have licensure etc separate from Qualifications? But we can treat licensure as part of Qualifications. So we skip Requirements.
We must not repeat job title as heading. Already not.
We must not include Pay/Schedule/Benefits sections.
We must output only HTML fragment.
Let's craft:
About the role
All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision to be among the kindest, highest quality health systems in the country.
Responsibilities
- Conducting and coordinating medical necessity reviews for all patients upon admission to inpatient or observation status and completing continued stay reviews throughout the stay.
- Evaluating surgical schedule for inpatient only procedures (IPOs) and communicating via message system the need for appropriate orders.
- Verifying physician orders in the medical record follow Medicare and other payer guidelines for determining level of care.
- Assuring medical documentation accurately reflects the severity of illness and acuity of the patient.
- Communicating with KHI medical staff as needed to reconcile and clarify admit orders and/or medical documentation to ensure that the hospital is reimbursed appropriately for services rendered.
- Consulting with Physician Advisor as needed to make medical necessity determinations and/or make referrals for cases not meeting criteria as per KHI Utilization Management Plan.
- Working collaboratively with Case Managers and Insurance Specialist to ensure that appropriate and accurate clinical information is communicated to payers within required timeframes as per KHI policies and procedures.
- Ensuring complete, accurate and timely entry of information related to the utilization review process into data systems.
- Maintaining documentation of all activities to support medical necessity determinations.
- Collaborating with all members of the healthcare team, the business office, and payers as necessary, to ensure patients receive high quality care in the most cost-effective manner.
- Collaborating with Denials Manager and RAC team to identify issues and/or trends related to medical necessity denials and participating in the denials management process.
- Serving as a resource to Case Management staff and providing education and coaching regarding appropriate use of clinical guidelines, utilization review and payer regulations.
- Establishing communications system for days off.
- Assisting in sending admitting and discharge clinicals on all patients.
- Reviewing Medical Records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria.
- Evaluating medical information against nationally recognized criteria and determining necessity for admission, continued stay, appropriateness of service, and/or level of care.
- Collaborating with physicians to determine appropriate inpatient versus observation status and ensure appropriate documentation and appropriate orders are entered.
- Performing Code 44 when needed and communicating downgrades to appropriate staff.
- Notifying Admitting, Insurance verifiers, and Apogee regarding status change of admission via email.
- Determining which cases will require medical staff review intervention and/or UR management intervention, considering factors such as appropriateness, quality, etc., during the Case Management process.
- Communicating with the attending physician, expected length of stay, Medicare guidelines and individual variances.
- Collaborating with the Case Managers and Insurance Specialist to ensure appropriate documentation, awareness of potential denials, and any needs of clarification within the EMR from physician.
- Assisting in educating Case Managers, Social Workers, and Physicians on changes in CMS guidelines, documentation requirements, etc.
- Protecting patients’ rights as they pertain to the ethical and legal issues of confidentiality during the case management process.
- Participating in committees, performance improvement activities, mandatory in-services, and continuing education.
- Maintaining compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines.
- Performing additional duties as requested, such as focused studies, appeal letters, outlier reporting, patient satisfaction initiatives, etc.
Qualifications
- Education: Graduate from an accredited school of nursing.
- Experience: Minimum of three years clinical experience as an RN preferably in a hospital medical surgical or critical care setting; minimum one year of utilization review experience or two years case management experience as an RN.
- Licensure: Current, valid Arizona or compact state RN license.
- Certification: N/A (preferred: BSN or MSN; CCM or ACM – will allow time to obtain).
Skills
- Strong clinical skills and knowledge, and the ability to recognize when quality issues exist.
- Knowledge of nationally recognized criteria used to make medical necessity determinations; experience using Milliman or InterQual criteria preferred.
- Strong interpersonal, organizational, and motivational skills, as well as proficiency in written and verbal communication.
- Effective problem‑solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
- Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open‑minded, and adaptable to change.
- Good assessment skills and knowledge of clinical and social factors that may affect the patient’s functional status at discharge.
Requirements
- Exposure Categories: Special Position Requirements Blood Borne Disease Exposure Category II; other potential hazard(s): Volatile/violent patients or family members.
- Work Requirements: Able to handle multiple priorities simultaneously; able to manage technical business equipment i.e., phone, fax, computer etc.; ability to sit for 5‑8 hours per day; ability to stand for 3‑5 hours per day; ability to walk for 3‑5 hours per day.