The utilization review (UR) nurse serves to maximize the quality and cost efficiency of health care services. Through regular utilization reviews and audits, the UR nurse ensures that patients receive the care they need without unnecessary diagnostic procedures, ineffective treatments or extended hospital stays. The utilization review examines how health care services are being utilized. The UR nurse requires extensive knowledge of patient care, medical treatments and hospital procedures. The UR nurse will rely on their clinical judgment, honed over years in acute care settings, to make responsible decisions that promote patient health and well-being while keeping resources available to those most in need. The UR nurse will also assist Registered Nurse (RN) Case Managers and Social Workers with helping patients make informed decisions about their health care by educating them on the benefits and limitations of their Medicare, Medicaid or private health care coverage.

SHIFT AND SCHEDULE

Full Time, Monday - Friday; 8:00 AM - 5:00 PM

ESSENTIAL FUNCTIONS/PERFORMANCE EXPECTATIONS

• Able to utilize electronic healthcare record (EHR) and billing systems, filter and prioritize UM Worklist, document Utilization Management (UM) reviews of various types, enter notes, locate insurance information, provide clinical updates to 3rd Party payors, place accounts on hold and release, and manage concurrent denials.

• Proficiently navigate within the EHR and the UM platform to gather documented information concerning the patient to establish appropriate utilization of hospital services.

• Conducts and documents an UM Review at time of admission or the next working day.

• Conducts and documents concurrent UM reviews no more than 3 days after admission review has been completed. Refers to Physican Advisor appropriately.

• Performs an in-depth Extended Stay review on patients with a stay greater than 5 days and refers to Physician Advisor appropriately.

• Utilizes and applies UM platform Care Level Scores along with clinical expertise, to validate medical necessity of the ordered admission status, appropriateness of treatment, and ordered level of care.

• Confers with attending physician or Physician Advisor when appropriate to make a determination about medical necessity.

• Communicates and works closely with insurance companies to ensure that the organization will be reimbursed for services rendered. Providing supporting documentation to justify medical necessity of the admission or continuation of stay.

• Assists and educates Medical Staff and other members of the healthcare team with regards to utilization issues such as, but not limited to:

     Admission Status

     Level of Care

     Medical Necessity

     Costs and best practices of treatment

     Expected Length of Stay (LOS)

• Functions as a resource to the healthcare team regarding approved criteria, practice guidelines, and alternative treatment options.

• Provides monthly reporting to the Utilization Management/Case Management Committee regarding inappropriate admissions.

• Assists with ensuring compliance with CMS Conditions of Participation for Utilization Review, Appendix A/§42 CFR 482.30

EDUCATION AND EXPERIENCE

Current State of Texas License as a Registered Nurse.

5 years of nursing experience (preferably in utilization management or hospital/acute care).

Computer proficiency in Microsoft Office

PHYSICAL REQUIREMENTS

· To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The individual must be able to: Ø Stand, walk, sit, stoop, reach, lift, see, speak and hear. Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non-clinical staff. The individual must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits.