Patient Care & Utilization Review Rn

This is a Full Time Position in Med/Surg-RN License required

Compensation Range: $33.58 to $50.38

Position Classification:
Non-Exempt

Essential Functions and Basic Duties:

Position Specific Performance Expectations:

Patient Care Specific:

• Tracks patient cases from admission to discharge. Ability to identify patients who are likely to suffer adverse health consequences upon discharge, needing coordination of support services, and follow-up care based on diagnosis and level of acuity.
• Conducts timely evaluations for all patients identified by their physician, patient, nursing, family or friend requests, or discharge planner inquiry as needing discharge planning.
• Ability to develop individualized care plan for patients needing patient care planning support.
• Ability to use critical thinking skills supporting patients in accessing all necessary applicable resources for follow-up care:
• From admission (regardless of status) ensures that patients are “pre-qualified” for hospital admissions.
• Continued admission (regardless of status) ensures that patients are “re-qualified” for hospital admissions.
• Conducts appeals on behalf of the patient and family (at time of service and for hospital stay denials).

• Develops discharge plans for patients to the most appropriate plans of care – understands the resources available and advocates for the patient for those resources.
• Understands Lifeline, Transition Care, Swing Bed, Home Health, Hospice, Nursing Home Services, and can discern and explain which resource may be best for a specific patient based on diagnosis and level of acuity.
• Fully understands transitional care and how that service works with a Critical Access Hospital.
• Ability to advocate for patients and negotiate with physician and ancillary staff for patients.
• Ability to advocate for patients with insurance companies and CMS for additional services.
• Expert at Inter Qual and/or Millimen clinical decision-support criteria.
• Ability to identify patients at risk for abuse, depression, falls, or other conditions. Follows the proper procedures for reporting.
• Gathers pertinent clinical information and applies and interprets criteria to ensure medical necessity, covered benefits, participating providers, and appropriate services.
• Advocates that the patient is placed in the appropriate level of care and program.
• Interfaces with program staff to facilitate a smooth transition at the time of transfer or discharge.
• Monitors patient charts and records to evaluate care concurrent with the patient’s treatment.
• Reviews treatment plans and status of approvals from insurers.
• Facilitates and coordinates discharge planning and works towards reduction of preventable hospital admissions, re-admissions, etc.
• Works closely with Revenue Cycle Department to ensure the insurance precertification process is complete and to update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
• Collects and compiles data as required and rendering with applicable hospital policies as well as state and federal guidelines.
• Communicates with clinical care team with any outstanding or concerning findings during utilization review including, but not limited to: failure to meet medical necessity, inappropriate admission status, etc.
• Communicates with providers to obtain any medical record documentation necessary to perform utilization review.
• Documents any UR needs or notes into Electronic Medical Record (EMR).
• Administers or participates in audits of programs to ensure agency compliance on utilization review regulations.
• Performs other duties as assigned.

Organization Wide Performance Expectations:

• Demonstrates 100% commitment to performing according to the CHOICE values of MRH and representing the organization in a positive and professional manner.
• Establishes and maintains effective verbal and written communication and good working relationships with all patients, staff and vendors.
• Adheres to MRH attire/dress code per policies and procedures.
• Utilizes initiative; strives to maintain steady level of productivity; self-motivated; manages activity and time.
• Completes annual…