RN Utilization Review, Peace Hospital

Primary

Location:

Peace – Louisville Address: 2020 Newburg Rd., Louisville, KY 40205

Shift: First Shift (United States of America)

UofL Health is a fully integrated regional academic health system with five hospitals, four medical centers, the Frazier Rehab Institute and Brown Cancer Center. The organization employs nearly 200 physician practice locations and over 700 providers to deliver patient-centered care to each and every patient each day.

The Utilization Review RN performs activities that support the Utilization Management functions. Responsibilities include making clinical recommendations regarding medical necessity for admission and continued stay, screening patients for client-specific guidelines, sending payor-specific Notice of Admission and continued stay reviews, communicating with physicians and case managers regarding payor approval/denial of admission and continued stay review, processing payor denials and retro reviews, and serving as a resource to physicians.

• Promotes optimal management of clinical resources by conducting timely admission and concurrent utilization review for all patients of designated medical services; certifies medical necessity for admission, continued stay and discharge reviews utilizing current MCG criteria and documents clinical information in Case Management Software.
• Evaluates the medical record during concurrent review to identify any process delays impacting timely patient care and ensures appropriate resources (e.g., physical therapy, cardiac rehabilitation, or nutritional service) are utilized.
• Maintains effective and efficient processes for determining appropriate admission status based on regulatory and reimbursement requirements of various commercial and government payers.
• Communicates closely with third‑party payors to secure authorizations and documents authorization information in the Case Manager Software.
• Advocates for patient/family needs in a respectful, confidential manner.
• Serves as a resource to physicians for clinical management and financial issues, assisting providers in promoting efficiencies and reducing barriers to effective service delivery.
• Reviews patient cases for potential problems with OIG Workplan Audits and compliance issues; reports problems and makes recommendations to appropriate departments.
• Appropriately refers cases to the manager/director of care coordination, CAO, or medical director when the intensity of service or severity of illness is not present or cannot be resolved.
• Educates physicians, patients, and staff regarding payors, financial issues, documentation, and potential compliance issues.
• Investigates and responds to billing concerns from Business Office, Health Information Management, Admitting, and other sources; resolves financial and billing problems such as appropriate patient status, correct payor source, denials, appeals, and system issues.

• Develops a cooperative relationship with third‑party reviewers to facilitate timely, positive responses for patient accounts.
• Attends Monthly Departmental Staff Communications Meetings and serves as an active member of committees, as needed.
• Enhances professional growth through participation in educational programs, current literature reviews, in‑service meetings and workshops related to assigned responsibilities.
• Maintains compliance with all company policies, procedures and standards of conduct.
• Complies with HIPAA privacy and security requirements to maintain confidentiality at all times.
• Performs other duties as assigned.

• Bachelor of Science in Nursing (required).
• RN with a bachelor’s degree in Business, Health Care Administration or equivalent may enroll in a BSN program within one year of employment and complete the BSN within three years.

• Two (2) years’ experience as an RN (required).
• Additional (1) year experience in case management/utilization management (preferred).
• Three years’ experience with Behavioral Health (required for positions at Peace Hospital).

• Active Kentucky Registered Nurse License or compact license with privileges to work in Kentucky.

• Case Management Certification (ACM, ANCC‑Nurse Case Manager or CCM) – preferred.