Utilization Review Nurse

Overview As a Utilization Review Nurse, you will work under the direct supervision of the Supervisor, Utilization Review and Clinical Documentation Improvement, this role will be responsible for providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. This includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Additionally, this role will be responsible for performing utilization review of all patients presenting for hospitalization to assist in identifying patients appropriate for admission to inpatient, observation, or other patient care status. This position conducts continued stay review evaluating the medical necessity, appropriateness and efficient use of health care services of all hospitalizations (inpatient & outpatient). This role will collaborate with the health care team to optimally certify the level of care. Qualifications Education: Associates Degree in Nursing. Bachelor's Degree in Nursing preferred. Evidence of continuing professional development.Licensure/Certification/Registry: Current RN licensure in the State of Illinois required. Experience: Minimum three years' recent hospital based patient care Minimum one (1) year experience with Milliman and/ or InterQual HMO, managed care, PPO, Utilization Management experience preferred Other Knowledge/Skills/Abilities: Demonstrate proficiency with use of Conditional Code 44, HINN, and Medicare Important Message Familiarity with coding concepts and coding software desired. Knowledge of care delivery documentation systems and related medical record documents Knowledge of age-specific needs and the elements of disease processes and related procedures Strong broad based clinical knowledge and understanding of disease processes Knowledge and skill in the use of computer software applications for drafting documents, data management, and tracking, especially those programs used by Passavant Area Hospital (PAH). Excellent communication, interpersonal, and organizational skills Responsibilities Professionally and courteously interacts with the patients, general public, physicians, hospital personnel, and outside entities. Uphold PAH's behavioral standards. Obtains and promotes appropriate clinical documentation through interaction with physicians, nursing staff and other patient caregivers to ensure documentation of the complexity and level of service rendered to the patient is complete and accurate. Collaborates with health care team to identify working DRG's Generates concurrent queries that are within corporate standards Participates in analysis and trending of statistical data for specified patient populations to identify opportunities for improvement Protects the confidentiality of the patient information at all times Develops a relationship with professional affiliations and others to maintain professional growth and development Keep detailed and concise records Demonstrates expertise in the application of Interqual and/ or Milliman criteria Reviews of clinical data for ED admits, making level of care recommendations to the ED physician and obtaining any additional clinical information that may assist in level of care determination Manages all direct admits, clarifying level of care orders and performing InterQual and/or Milliman screening as appropriate. Acquires additional information if necessary to assist in level of care determination. Reviews all request for changes in status for admission from outpatient surgery or other areas. Insures operative procedure performed is the operative procedure prior authorized with the third party payor and communicates any variance Monitors use of healthcare resources. Communicates with physicians to assure patient receives diagnostic/ evaluations in the proper setting (i.e. inpatient vs outpatient) Maintains current knowledge of payor rules and regulations, especially CMS (Medicare) Serves as an expert resource to physicians and healthcare staff in the application of InterQual/ and or Milliman criteria Conducts observation reviews daily Conducts initial admission reviews at the time of presentation, or within 24 hours, if patient presents during uncovered hours Conducts concurrent review per department policy and as a private payor dictates Follows department policy regarding escalation of utilization issues to the Physician Advisor or his/her designee. Communicates length of stay (LOS) or coverage concerns for Utilization Review agencies to the patient care team and Provider. Participates in Care Conferences as needed. Reviews all denial received for potential appeals, initiates telephonic or written appeal, logs information, and completes documentations follow up for appeal outcome. Performs other related work as required or requested. The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.