Utilization Review RN - Patient Bus Svs

Job Description

The Utilization Management RN reports directly to Utilization Review RN Coordinator. The UR RN supports the UR RN Coordinator and other UR team members in providing all identified utilization review functions for the organization to ensure cost effective care delivery.

In collaboration with the patient/family, physicians, and the interdisciplinary team, the UR RN ensures the care delivery systems at SPH are utilized effectively and efficiently; engages the UR RN Coordinator with improvement ideas when deviations of best practice are noted. The UR RN serves as an advocate for the patient and family throughout the continuum of care and serves as a collaborative and supportive liaison and educator to providers and staff around utilization management principles.

• Stay current on insurance issues and proactively educate/notifies UR RN Coordinator of pertinent changes.
• Maintain confidentiality of hospital, patient, and family information.
• Must be able to interact with various hospital staff and departments at all levels possessing positive communication skills and compassionate competence.
• Apply medical knowledge and experience for prior authorization requests.
• Perform detailed medical reviews of prior authorization request or assessment forms according to established criteria and protocols.
• Manage incoming authorization requests and inquiries via email, fax, computer, telephone, or mail.
• Maintain accurate documentation on all requests and documenting in the appropriate computer application.
• Initiate and continue direct communication with health care providers involved with the care of the patient to obtain complete and accurate information.
• Follow-up on Peer to Peer requests including scheduling these to be completed between the facility and plan providers.
• Review insurance companies’ requests for change of patient status using MCG guidelines then negotiate with insurers to obtain the maximum payment possible for the claim.
• Collaborate real-time with medical staff to assure correct admission status and confirm treatment goals, treatment plan, and clinical mileposts used to advance the treatment plan.
• Coordinate patient information to assure timely reviews according to UR work plan and follow-up with physician consultants.
• Confirm admission diagnosis and correct admission status and identify related quality measures to promote medical compliance.
• Collaborate with admitting physician, ED physicians, Hospitalists, Documentation Specialist, and other ancillary staff to assist with the initial patient assessment and high risk screen for the purpose of resource management.
• Provide point-of-care coaching to the medical staff for documentation improvement and observance of quality indicators to support admission status.
• Evaluate denials for appropriateness for appeals versus billing at an alternate level of care.
• Track and follow-up on submitted appeals, adjustments, and reconsiderations.

• Work independently to provide coverage for UR activities during weekend days while other UR team members are out of the office.
• Complete comprehensive review of all admissions to SPH. These are evaluated for admission status.
• Follow-up daily on all communication with the MD advisor or physician consultant(s) on any cases sent for physician review.
• Performs daily utilization reviews on all patients admitted the day prior.
• Continued stay reviews daily.
• Documentation of avoidable days of care within Epic.
• Using MCG severity of illness/intensity of service criteria, evaluate the patients’ status and need for acute care services to assure appropriateness of the admission status and communicate when needed with the other UR team members.
• Works closely with hospitalist team providers, outside providers, and staff to assure patients who are admitted are meeting the appropriate criteria for the status order(s).
• Contact the attending provider for variations in status from that of criteria and/or physician advisor recommendations.
• Enter appropriate status orders into Epic as they are received for admission status changes deemed appropriate by the attending provider.
• Participate in orientation…