Utilization Review RN

Job Type
Full-time

Responsible for review of all inpatient and outpatient admissions to the hospital for appropriateness and manages all access points for admission to the hospital including but not limited to Emergency Department admissions, direct admissions, transfers into and out of the ED, other facilities, and admissions from outpatient areas. Evaluates the medical necessity, appropriateness, and efficient use of health care services of all hospitalizations, inpatients or outpatients.

Skilled with the application of Inter Qual and MCG criteria, works collaboratively with the physicians, healthcare team and the care coordinator to optimally certify the level of care and facilitates the patient’s movement through the continuum of care as appropriate.

Responsible for review of all inpatient and outpatient admissions to the hospital for appropriateness and manages all access points for admission to the hospital including but not limited to Emergency Department admissions, direct admissions, transfers into and out of the ED, other facilities, and admissions from outpatient areas. Evaluates the medical necessity, appropriateness, and efficient use of health care services of all hospitalizations, inpatients or outpatients.

Skilled with the application of Inter Qual and MCG criteria, works collaboratively with the physicians, healthcare team and the care coordinator to optimally certify the level of care and facilitates the patient’s movement through the continuum of care as appropriate.

• Monitor use of healthcare resources, collaborate with physicians to ensure patient receives diagnostics/evaluations in the proper setting (i.e. inpatient vs. outpatient).
• Maintain current knowledge of Condition Code 44, Hospital CoP’s and CMS (Medicare) rules and regulations.
• Serve as an expert resource to physicians, healthcare staff in the application of Inter Qual and MCG, and use of evidence-based practices.
• Serve as patient advocate and enhance a collaborative relationship between the physician and multidisciplinary team with the patient and family to maximize informed decisions.
• Communicate effectively with third party payors regarding certification, completes initial review prior to or at time of admission.
• Maintain knowledge of Inter Qual and MCG medical necessity criteria and apply appropriately.
• Identify the need to clarify documentation through quality audits in records and initiate communication with physicians utilizing appropriate ‘query’ tools in order to capture documentation in the medical record to accurately support the patient’s severity of illness.
• Demonstrate knowledge of documentation requirements and guidelines.
• Assist in the improvement of overall quality and completeness of clinical documentation by ensuring that documentation clarification with physicians has been recorded in the patient’s chart.
• Review clinical data for ED admits, make level of care recommendations to the ED physician, and obtain any additional clinical information to assist in the level of care determination.
• Manage all direct admits, clarify level of care orders and perform Inter Qual screening as appropriate. Acquires additional information if necessary to assist in the level of care determination.
• Review all requests for changes in status for admission from the PACU or any outpatient areas. Apply Inter Qual and MCG criteria to determine appropriateness for the level of care requested and consult with Attending if necessary.
• Ensure the operative procedure performed is the operative procedure prior-authorized with the third-party payor and communicate any variance.
• Serve as a resource for facilitating patient transfers, including but not limited to, obtaining or providing clinical information from/to the referring/accepting facility. Perform clinical reviews of all inbound transfers for appropriateness.
• Demonstrate a working knowledge of HIPAA guidelines and utilize them in all aspects of communication with customers.
• Cooperate/communicate with the QIO when a Medicare patient has appealed for their discharge.
• Consult the Physician Advisement process to resolve issues and refer…