Utilization Review Nurse

Penn Medicine, University of Pennsylvania Health System · West Chester, PA · 2 wk ago

HealthcareFull-time

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

About the role

The Utilization Review Nurse will provide utilization review for authorization, concurrent review, and discharge review services using InterQual criteria guidelines to validate medical necessity and appropriateness of the treatment plan. Uses critical thinking and leadership skills to ensure patients are at the appropriate level of care, safely transitioned across the healthcare continuum, and third-party payor standards are met. Reports to the Utilization Review Committee responsible for ensuring appropriate utilization review practices to decrease LOS/readmissions, prevent financial loss, and lower financial risk. The Utilization Nurse will seek out and resolve discrepancies or delays in the care delivery process, ensuring appropriate services are generated in a timely and cost-effective manner.

Responsibilities

Works collaboratively and maintains active communication with physicians, nursing, and other members of the multi-disciplinary care team to effect timely, appropriate patient management.
Assesses patient progress through the expected in-house course, mobilizing resources of the patient care team to ensure patient outcomes are achieved as planned.
Serves as the liaison between third-party payors and actively participates in denial management activities.
Works with physicians in documenting medical care to accurately and completely reflect intensity of service and severity of illness.
Evaluates the appropriateness of continued stay by performing concurrent review and reviewing planned interventions with the physician. Makes appropriate recommendations for continued stay and/or modification of the care plan and course of treatment.
Consults and advises members of the interdisciplinary team and ancillary staff to facilitate patients toward targeted outcomes.
Collaborates appropriately with physician advisor to avoid denials.
Serves as preceptor to new hires.
Identifies trends in inappropriate utilization of resources, including, but not limited to, delays in diagnostic testing, medical surgical procedures, and physician management.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competence; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff.
Communicates relevant clinical information, including admission review, concurrent review, and discharge planning needs, to third-party payors to secure optimal reimbursement.
Applies InterQual criteria to monitor appropriateness of admissions and continued stays and documents findings in the electronic health record.
Follows 100% of assigned inpatient admissions.
Determines medical appropriateness of the patient’s admission (severity of service).
Monitors the plan of care and proactively identifies barriers to the plan (intensity of service).
Intervenes to avoid delays in the plan of care.
Coordinates the flow of clinical information with third-party payors to ensure appropriate reimbursement and proactively identifies potential denials to avoid non-appealable denials.

Requirements

Registered Nurse - PA (Required)
Certified Case Manager

Qualifications

Associate of Arts or Science (Required) – Major/Area of Study: Nursing/ASN OR Bachelor of Arts or Science – Major/Area of Study: Nursing/BSN
3+ years of nursing experience
1+ years of utilization review experience

Benefits