Utilization Review Specialist RN PRN

Utilization Management Dept.

PRN

Any

Variable

Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care.

Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region s third largest employer.

Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.

Job Summary
Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting. Follows patient throughout hospitalization collaborating with attending physician and other health care providers. Communicates with third party payors to obtain authorization. Contributes to appropriate throughput and length of stay. Assists with denial management. Reviews physician medical record documentation and consults with physicians regarding completeness.

Minimum Qualifications


Minimum Education : ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing
Minimum Years of

Experience:

3 Years of experience in an acute care hospital setting
Substitutable

Education & Experience:

None.
Required Certifications/Licensure:
Registered Nurse currently licensed in the State of South Carolina
Required Training:
None.

Essential Functions

• Works in a cooperative manner, which fosters favorable relations between employees and patients, patients  families, visitors, fellow employees, and the medical staff. Accepts chain of command, supervision, and constructive criticism.
• Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests.
• Contributes to teamwork and creates harmonious, effective and positive working relationships with others.
• Respects, understands, and responds with sensitivity to employees and guests by treating others as one would wish to be treated.
• Resolves conflicts and problems-solves by remaining calm when confronted, attempting to identify solutions or referring person to appropriate authority and attempting to deliver more than is expected.
• Exhibits telephone courtesy by:
  • Answering promptly with name and department.
  • Speaking with pleasant tone while focusing on caller.
  • Transferring calls correctly and promptly.
  • Attending to calls on hold in a timely manner.
  • Maintains confidentiality by:
    • Discouraging gossip.
    • Using discretion when discussing patient, work, or LMC-related information with others.
    • Utilizes the service recovery process to resolve complaints (GIFT).
    • Demonstrates competence in providing duties within role.
    • Demonstrates competence to provide developmentally appropriate planning/review for patients of all age groups.
    • Identifies need for professional growth and seeks appropriate professional development opportunities attaining a minimum of 15 hours of continuing education in topics related to the role annually.
    • Serves as role model for other members of the health care team.
    • Demonstrates receptiveness to change and flexibility in meeting department needs.
    • Assists in orientation and training of staff.
    • Performs admission and continued stay medical record review to gather information to support medical necessity of the admission and communicate with third party payors.
    • Performs timely review of admissions utilizing Inter Qual criteria to assess for appropriate level of care assignment. Reviews both inpatient admissions and patients placed in Observation.
    • Incorporates applicable governmental regulatory guidelines in effect for Medicare and/or…