Utilization Review Nurse-RN - Main Case Management - Full Time - Days

Responsibilities

• Utilize an Integrated Case Management Model to follow patients through the continuum.
• Facilitate utilization review, utilization management, and cost containment functions.
• Track and trend denials and payor issues to provide feedback and education.
• Review 100% acute bedded patients admitted to Inpatient or Observation status against medical necessity criteria.
• Maintain efficient methods to ensure medical necessity and appropriateness of all hospital admissions.
• Identify and facilitate patient status transitions from observation to inpatient as clinically appropriate.
• Comply with all Medicare regulatory requirements and secure payer authorizations for services.
• Monitor cases for appropriateness of continued stay, level of care, and quality of care.
• Communicate with physicians regarding clinical reviews and alternative care options.
• Refer cases needing second-level review to the Physician Advisor.
• Collaborate with RN Case Managers to prevent extended length of stays and ensure appropriate status determinations.
• Identify and refer potential delays in service or treatment to appropriate team members.
• Track and trend avoidable days in Midas according to process.
• Identify and report problems related to patient care quality.
• Ensure adherence to department productivity standards.
• Complete initial, concurrent, and retrospective reviews timely with relevant information for claim approval.
• Document reviews only pertinent to Intensity of Service/Severity of Illness.
• Interface with patient registration and financial services to address financial issues.
• Build and maintain relationships with third-party payers to promote cost-effective clinical outcomes.
• Assist in the denial and appeal process.

Qualifications

• Specialized knowledge and skills required for a Utilization Review Nurse.
• Compliance with department and hospital policies.
• Conformance to State/Federal Guidelines and standards.
• Adherence to Medicare requirements.
• Continuous learning and staying updated on changes in laws and requirements.
• Professional responsibility required for the position.
• Knowledge and application of advanced case management tools and methods.
• Knowledge of clinical and operations research methodology and design.
• Expertise in business trends, benchmarking, and case management tools and techniques.
• Proficiency in operating PC-based software and automated database management systems.
• Strong presentation, written, and oral communication skills.
• Strong analytical and problem-solving skills.
• Time/project management skills.
• Ability to work with various disciplines and levels of staff.
• Licensed to practice in the State of Ohio.
• Certified Case Management (CCM) or Accredited Case Management (ACM) preferred.