Rn-Case Management (Utilization Review)

Job Summary: Utilization Review Nurse II represents the fully experienced level in utilization review and discharge planning activities. Job Responsibilities:

• Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present.
• Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions.
• Conducts on-going reviews and discusses care changes with attending physicians and others.
• Formulates and documents discharge plans.
• Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources.
• Identifies pay source problems and provides intervention for appropriate referrals.
• Coordinates with admitting office to avoid inappropriate admissions.
• Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary.
• Reviews and approves surgery schedule to ensure elective procedures are authorized.
• Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services.
• Answers questions from providers regarding reimbursement, prior authorization and other documentation requirements.
• Learns the documentation requirements of payor sources to maximize reimbursement to the hospital.
• Keeps informed of patient disease processes and treatment modalities.
• Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital.
• May assist in training Utilization Review Nurse I workers.
• Performs other job-related duties as assigned. Required Skills & Experience: -(Level I) Two (2) years of experience or its equivalent as a registered nurse in an acute care hospital.
• At least one (1) year of experience must be on a medical/surgical ward or unit. -(Level II) One (1) year of utilization review/discharge planning experience in an acute care hospital. OR
• Two (2) years of experience as a Case Manager in an alternate medical setting such as a clinic or physicians office performing utilization review or discharge planning.
• Knowledge of payor source documentation requirements and governmental regulations affecting reimbursement.
• Knowledge of acute care nursing principles, methods and commonly used procedures.
• Knowledge of common patient disease processes and the usual methods for treating them.
• Knowledge of medical terminology, hospital routine and commonly used equipment.
• Knowledge of acute hospital organization and the interrelationships of various clinical and diagnostic services.
• Ability to effectively evaluate the medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans.
• Ability to assess and judge the clinical performance of physicians and other health professionals.
• Ability to communicate documentation needs in an effective and tactful manner that promotes cooperation.
• Ability to teach co-workers what is needed and required in the medical record for reimbursement and audit purposes.
• Ability to gather and analyze data and prepare reports and recommendations based thereon.
• Ability to get along with physicians, other health providers, outside payor sources and the general public. Preferred Skills & Experience: -N/A