RN Utilization Review II-Behavioral Health

Overview

Utilization review nurse is responsible for the day to day coordination of admission criteria as it relates to the healthcare needs of the patient and organization, including knowledge of regulatory and compliance with Medicare, Medicaid and other insurance payors. This team member will communicate with a variety of clinical disciplines, commercial payers, patient access, patient financial services, physician advisor and other staff members.

• Provides initial, concurrent and retrospective reviews for severity of illness and intensity of service when assigned to patients.
• Interprets Inter Qual and Milliman and Roberts criteria to ensure patients meet admission and continued stay criteria.
• Provides accurate and complete account authorization and details in plan notes.
• Performs admission review on the business day following the patient's admission.
• Involves the Physician Advisor as needed when physician-to-physician interaction is required to achieve appropriate clinical utilization for the patient.
• Collaboratively works with the Physician Advisor to facilitate all aspects of the utilization management plan.
• Acts as a liaison to patient accounting and patient access as it relates to authorizations and claims.
• Demonstrates ability to communicate effectively with internal and external customers.
• Demonstrates commitment toward customer satisfaction and patient advocacy.
• Maintains confidentiality of patient, physician, and other team members and compliance with all federal/state guidelines and regulations.
• Achieves budget length of stay (LOS) goal.
• May perform other duties as assigned or requested; job specifications can be modified or updated at any time.

• Required Education: Graduate of an accredited Nursing Program.
• Preferred Education: Bachelor of Science Degree in Nursing (BSN).
• Required Experience: Three (3) years of experience in acute care nursing. Computer skills are a must, as well as excellent communication and the ability to work collaboratively with other disciplines.
• Required Certifications and Licensures: Hold a current, active license as a registered nurse in Virginia or hold a current multistate/compact license. Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card.
• Preferred Certifications and Licensures: ACMA Certification.