Utilization Review Nurse (U)

About the role

The Case Manager RN (U) coordinates the overall interdisciplinary plan of care for patients, from admission to discharge. They monitor care and act as a liaison between patient/family, healthcare personnel, and insurers. They evaluate the needs of the patient, the resources available, and recommend and facilitate the plan for the best outcome. They develop a discharge plan that provides the best available resources to meet ongoing patient needs and encourages compliance with medical advice.

Responsibilities

• Evaluate the needs of the patient, the resources available, and recommend and facilitate the plan for the best outcome.
• Develop a discharge plan that provides the best available resources to meet ongoing patient needs and encourages compliance with medical advice.
• Identify patient care issues and suggest revisions to or new clinical pathways to improve quality of care.
• Facilitate care progression, timely consultations and testing, assure social service intervention, and individual discharge planning.
• Affirm the transfer or discharge of a patient to another level of care, treatment, services or different setting is always based on the patient’s assessed needs, patient’s insurance coverage benefits, and the organization’s capabilities to meet these needs.
• Monitor resource consumption and capture of avoidable days. Enter Ancillary notes utilizing the templates for care facilitation.
• Proactively assure the orders needed are obtained and facilitate delivery of clinical and community services to patients and families through effective utilization of available resources.
• Attend daily multidisciplinary huddles, meeting facilitation/address progression of care.
• Ensure the appropriateness and cost-effectiveness of patient’s plan of care based on DRG.
• Proactively collaborate with physicians(s) to develop patient care plans and review medical needs for continued hospital services and resource consumption.
• Utilize Case Manager nurse-driven protocols to facilitate care and request physician orders on items not part of CM nursing protocol.
• Provide all required Medicare documents to the patient and/or proxy when applicable, inclusive of the discharge Important Message from Medicare, Code 44 patient notification required documents.
• Process QIO Medicare appeals.
• Attend and facilitate the daily multi-disciplinary huddles.
• Attend and report on assigned LOS 10-day outliers - Complex Case Review.
• Communicate to management daily on observation outliers related to care transition and discharge barriers.
• Identify the patients’ risk factors or obstacles to care, and discharge and readmission risk.
• Evaluate the plan of care regularly by chart review and patient interviews, as well as collaborate with the medical team to facilitate the patients’ movement through the system.
• Educate patients and families on the progression of care.
• Serve as a liaison between patients, families, and healthcare personnel to ensure necessary care is provided promptly, effectively, and in a fiscally responsible manner.
• Promote quality care to ensure patients receive medically appropriate services in appropriate status and stay standards.
• Facilitate regulatory notifications and patient signatures per policy.
• Maintain knowledge regarding insurance reimbursement policies.
• Adhere to University and unit-level policies and procedures and safeguard University assets.

Qualifications

• Education: Bachelor’s Degree in relevant field.
• Certification and Licensing: Registered Nurse (RN) License.
• Experience: Minimum 7 Years Of Relevant Experience (5 years of case management/utilization review experience).
• Knowledge, Skills and Attitudes: Ability to communicate effectively in both oral and written form. Ability to recognize, analyze, and solve a variety of problems. Ability to analyze, organize and prioritize work under pressure while meeting deadlines. Ability to maintain effective interpersonal relationships.

Benefits

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

Pay

Competitive salary offered.

Schedule

Full-time position.