Registered Nurse (RN) - Utilization Review - Acute Care PT Weekends (Sat/Sun 7am-7pm)

Job Summary

The Utilization Management (UM) Nurse is responsible for conducting medical necessity reviews up to 12 hours per day, on any of the 7 days per week, utilizing Indicia for Case Management, and performs clinical reviews through document review, discussion with physicians and collaboration with the care team on the coordination of safe transitions of care for a defined patient population.

The UM Nurse will perform utilization review every day by looking at all new admissions, all observation cases and concurrent reviews. They will be assigned to specific units and/or payer and/or patient class. All clinical reviews will be done by utilizing MCG Indicia, Indicia for Admission Documentation (IAD), and Indicia for Effective Focus (IEF) criteria in conjunction with medical records documentation and communication with physicians and physician's advisors.

The UM nurse gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to complete the determination/recommendation for the most appropriate level of care status and shares pertinent clinical information to the payers. Along the continuum of care, the UM Nurse communicates with providers and other parties to facilitate care/treatment.

The UM Nurse identifies opportunities to ensure effectiveness of healthcare services in the most appropriate setting, as well as timely discharge to the most appropriate level of post discharge care. The UM Nurse obtains timely authorization of all ALOS days from payers and ensures accurate and complete documentation in EPIC to enable timely billing.

The UM RN monitors post-discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies that will result in the account being denied by the payor that require clinical expertise. The UM Nurse communicates with third party payors to resolve discrepancies prior to billing, accurately and concisely documents all communications and actions taken on the account, and escalates medical review request and/or denial activities to management as needed.

Core Responsibilities and Essential Functions

Utilization Management

• Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG).
• Ensures timely identification of need and referral for alternative level of care.
• Responsible for timely and accurate certification/authorization of hospital admissions and hospital days.
• Provides required information to payors in a timely fashion and obtains appropriate authorization for all days. Ensures authorizations are documented in EPIC in a timely manner.
• Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards, utilizing screening criteria to determine level of care with documentation.
• Monitors and evaluates the appropriateness of managed care denials and collaborates with attending physician, physician advisors and managed care representative to overturn denials.
• Monitors for compliance of Medicare/Medicaid regulations.
• Advocates for patient and negotiates and refers for services that may be required outside of patient's health care coverage.
• Identifies, participates, and supports continuous performance improvement initiatives based on identified opportunities.
• Ensures appropriate compliance with payer regulations and that all information is well documented to prevent payer disputes and denials.

Assessment

• Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG).
• Assesses insurance and coverage requirements for all payers and ensures adherence to those requirements at all times.
• Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution.

Documentation and Post Discharge

• Completes chart notes accurately and on time per Departmental protocol.
• Ensures all records are up-to-date.
• Ensures timely and accurate documentation of clinical reviews and insurance updates as required by payor including authorized days and denied days with reason for denial.
• Works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no auth numbers, ALOS vs. authorized days or other discrepancies.
• Evaluates clinical documentation in patient records and escalates issues through the established chain of command.

Professional Development and Initiative

• Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
• Serves as a preceptor and/or mentor for other professional and/or students.
• Performs other duties as assigned.
• Complies with all WellStar Health System policies, standards of work, and code of conduct.