Utilization Review Nurse; RN

Job Information

• Job Category: UTILIZATION MANAGEMENT, CARE MANAGEMENT, NURSING
• Employee Type:
  Full-Time

JOB PURPOSE OR MISSION: Responsible for utilization of clinical and financial resources by: ensuring appropriate clinical level of care, performing and submitting clinical information to external payers to secure proper authorization, collaborating with the Care Coordinator in the development and implementation of the plan of care, serving as a primary resource to the Utilization Review Nurse I (LPN), and ensures prompt notification of any denials to the appropriate Care Coordinator, Denials/Appeals Coordinator, and Team Leader.

Performs all job duties for the age population served, as defined in the department’s scope of service.

• Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
• Takes initiative in living our Everyday Excellence values and vital signs.
• Takes initiative in identifying customer needs before the customer asks.
• Participates in teamwork willingly and with enthusiasm.
• Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
• Keeps customers informed, answers customer questions and anticipates information needs of customers.

• Practices diligence in fulfilling the regulatory and legal requirements of the position and department.
• Maintains accurate and reliable patient/organizational records.
• Maintains professional relationships with appropriate officials; communicates honesty and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.

• Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
• Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
• Upholds the ethical standards of the organization.

• Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.
• Initiates or redesigns to continuously improve work processes.
• Contributes ideas and suggestions to improve approaches to work processes.
• Willingly participates in organization and/or department quality initiatives.

• Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.
• Employee proactively reports errors, potential errors, injuries or potential injuries.
• Employee demonstrates departmental specific patient and employee safety standards at all times.
• Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures and plans.

Performance Standards:

• Identifies accurate payer information for each assigned patient.
• Communicates and collaborates with admission/precertification department to ensure appropriate payer precertification is completed for level of care status.
• Performs admission review on all assigned inpatients and observation patients within one business day of admission for appropriateness of admission and level of care based on medical necessity utilizing Inter Qual criteria.
• Refers appropriate cases to physician advisor or designee, communicating via Provider Link and/or telephonically.
• Communicates with admitting physician as needed to ensure the correct admit level of care status.
• Performs concurrent review on all assigned patients for appropriateness of level of care and continued stay based on medical necessity utilizing Inter Qual criteria as required by external payers.
• Contacts physician and/or Care Coordinator for additional information regarding cases not meeting medical necessity criteria for admission and continued stay reviews.
• Identifies and refers problem cases to appropriate Care Coordinator and/or supervisor.
• Maximizes reimbursement to BRGMC by:
  • Communicating pertinent clinical information to payers.
  • He…