Utilization Review Nurse

Department/Unit: Care Management/Social Work – Day shift (United States of America)

About the Role

Responsible for Utilization Management, Quality Screening, and Delay Management for assigned patients. Completes Utilization Management and Quality Screening, applying MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards.

Responsibilities

• Perform utilization review to identify areas for clinical documentation improvement and contact appropriate departments.
• Identify at-risk populations using approved screening tools and follow established reporting procedures.
• Monitor length of stay (LOS) and ancillary resource use, taking actions to achieve continuous improvement.
• Refer cases and issues to the Medical Director and Triad Team in compliance with Department procedures and follow up as indicated.
• Communicate covered day reimbursement certification for assigned patients.
• Discuss payor criteria and issues with clinical staff on a case-by-case basis and resolve problems with payors as needed.
• Use quality screens to identify potential issues and forward information to the Quality Department.
• Demonstrate proper use of MCG and documentation requirements through case review and inter-rater reliability studies.
• Facilitate removal of delays and document delays when they exist; report internal and external delays to the Triad Team.
• Collaborate with the healthcare team and appropriate departments to manage care across the continuum by ensuring communication with the Triad Team and healthcare team.

Requirements

• Registered nurse with a current New York State license.
• Associate’s degree required; Bachelor’s degree preferred.
• Minimum of three years of clinical experience in an assigned service.
• Recent experience in case management, utilization management, and/or discharge planning/home care in a high-volume, acute care hospital preferred.
• PRI and Case Management certification preferred.
• Assertive and creative in problem-solving, with strong critical thinking and systems planning skills.
• Self-directed with the ability to adapt in a changing environment.
• Basic knowledge of computer systems with skills applicable to the utilization review process.
• Excellent written and verbal communication skills.
• Working knowledge of MCG criteria and ability to implement and utilize.
• Understanding of Inpatient versus Outpatient surgery, ICD-10 coding (preferred), and Observation status qualifications.
• Ability to work independently and demonstrate organizational and time management skills.
• Strong analytic, data management, and PC skills.
• Working knowledge of Medicare regulatory requirements and Managed Care Plans.

Pay

$77,075.00 - $119,466.00