Utilization Review Nurse - Medication Access

Responsibilities

• Applies approved utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review.
• Communication to third-party payers for initial and concurrent clinical review.
• Reviews patient chart to ensure patient continues to meet medical necessity.
• Documentation of all actions and information shared with care team members or third-party payer.
• Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay.
• Discusses with physicians the appropriateness of resource utilization.
• Tracks length of stay (LOS) and resource utilization to identify at risk patients.
• Refers to UR committee any case that surpasses expected LOS, expected cost, or over/under-utilization of resources.
• Performs verbal/fax clinical review with payer as determined by nursing judgment and/or collaboration with the payer per university contractual obligation.
• Participant in UR Committee as needed.
• Collections data on variances in LOS, avoidable days, costs/barriers to discharge/transition and denied days.
• Prepares appeals on denied cases when appropriate.

Requirements

• One year Utilization Review or Case Management experience.
• Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah.
• Maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah.

Qualifications

• Knowledge of ICD-10, CPT Codes, and medications HCPCS.
• Knowledge of CMS Regulations.
• Knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.
• The ability to demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.

Skills

• Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment.
• Ability to perform the essential functions of the job as outlined above.
• Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills.

Physical Requirements

• This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects.
• This position involves sitting most of the time and is not exposed to adverse environmental conditions.
• This position does not provide care to patients.
• Carrying, Color Determination, Crawling, Far Vision, Lifting, Listening, Manual Dexterity, Near Vision, Pulling and/or Pushing, Reaching, Sitting, Speaking, Standing, Stooping and Crouching, Walking.