Utilization Review RN Utilization Resource Mgmt Pennington NJ

Position Overview

Cap​ital Health is the region's leader in providing progressive, quality patient care with investments in our physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource with two hospitals, an outpatient center, satellite ED, and a network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. We aim for flexibility in structuring competitive compensation offers to attract the best candidates.

The listed pay range reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

• Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care.
• Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self-pay patients, based on appropriate guidelines. Uses these criteria to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate to the UR physician advisor for review and determination.
• Gathers clinical information to conduct continued stay utilization review activities with payers daily. Performs concurrent and retrospective clinical reviews with various payers, adhering to CMS guidelines and applicable regulations, policies and timelines. Identifies, develops and implements strategies to reduce length of stay and resource consumption.
• Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry.
• Keeps current on regulatory changes affecting delivery or reimbursement of acute care services. Advises physicians using knowledge of national and local coverage determinations.
• Understands and applies federal law regarding Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters.
• Identifies and records progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program.
• Consults with medical staff, care team and case managers to resolve progression of care barriers through appropriate channels.
• Engages care team colleagues in collaborative problem solving regarding resource utilization.
• Recognizes and responds to patient safety and risk factors.
• Represents Utilization Management at committees, professional organizations and physician groups as needed.
• Promotes evidence-based protocols and order sets to influence high quality and cost-effective care.
• Participates in performance improvement activities and ensures medical documentation reflects findings, interventions, and patient needs for continued stay.
• Maintains documentation in the Utilization software system on each patient for all resource utilization activities.
• Participates in daily huddles, patient care conferences, and hospitalist or nurse handoffs to monitor intensity of services and progression of care.
• Identifies wasteful or misused resources and recommends alternatives by analyzing clinical protocols.
• Maintains related continuing education credits (15 per calendar year).

• Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred.
• Experience: Three years of clinical nursing or two years in quality management, utilization review or discharge planning.
• Other Credentials: Registered Nurse - NJ
• Knowledge and
  
  Skills:
  
  Three years of clinical nursing or two years quality management, utilization review or discharge planning. CPHQ, CCM or CPUR preferred.
• Special Training: Basic computer skills including Microsoft Office, UR software and EMR. Familiarity with MCG guidelines.
• Mental, Behavioral and Emotional Abilities: Ab…