RN - Utilization Review - Utilization Review

Job Summary

RN-Utilization Review is accountable to perform utilization management services for designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the utilization management process to the appropriate manager.

Education & Experience

• One (1) year of nursing experience in an inpatient setting.
• Valid RN license.

Responsibilities

• Performs prospective, concurrent, retrospective, and denials review for individual cases, including benefit coverage, medical necessity, appropriate level of care, and mandated services.
• Aids in collecting and reporting financial and performance indicators, including case mix, length of stay, cost per case, resource utilization, readmission rates, denials, and appeals.
• Uses data to drive decisions and implement performance improvement strategies related to case management, including fiscal, clinical, and patient satisfaction outcomes.
• Collects and analyzes variances from the plan of care and collaborates with physicians and the healthcare team to address issues and improve outcomes.
• Applies clinical appropriateness criteria to monitor admissions and continued stays, identifies at-risk populations, and refers cases to the care management physician advisor as needed.
• Communicates with third-party payers to facilitate reimbursement certification, resolves payor issues, and completes utilization management and quality screening for assigned patients.
• Works collaboratively with the interdisciplinary care team to ensure timely, appropriate patient management, remove barriers to care, and proactively address delays or discharge obstacles.
• Safeguards safe, high-quality care in compliance with policies, procedures, and standards, while managing time, supplies, productivity, and accuracy within budgetary guidelines.

Physical And Environmental Demands

• Occasional exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold.
• No handling or working with potentially dangerous equipment.
• Occasional working hours beyond regularly scheduled hours.
• Occasional travelling to offsite locations.
• Occasional activities subject to significant volume changes of a seasonal/clinical nature.
• Occasional work produced is subject to precise measures of quantity and quality.
• Occasional bending.
• Occasional lifting/carrying up to 10 pounds.
• Occasional lifting/carrying up to 25 pounds.
• No lifting/carrying up to 50 pounds.
• No lifting/carrying up to 75 pounds.
• No lifting/carrying up to 100 pounds.
• No lifting/carrying 100 pounds or more.
• No climbing.
• No crawling.
• Occasional crouching/stooping.
• Frequent sitting.
• Frequent standing.
• Frequent walking.
• Occasional kneeling.
• Occasional pushing/pulling.
• Occasional reaching.