Registered Nurse (RN) | Utilization Review

Avera•Sioux Falls, SD

3d•$31 - $46

About The Position

Reviews current admissions, hospital stays, retrospective inpatient and observation cases to determine accurate level of care determination based on primary and/or secondary insurance payment requirements as well as scheduled/booked surgical. This position is responsible to obtain a signed inpatient order is on the account for all Medicare inpatient only procedure cases. The position collaborates with clinicians and financial team members including the Pre-anesthesia Department, Surgery Scheduling, Clinical Departments, physicians, payers, Patient Access, Health Information Management, and Case Management. Demonstrates a willingness to maintain awareness of the business of medicine and transitional healthcare changes including but not limited to value-based purchasing ,bundled payments, accountable care organizations and the readmission reduction program.

Requirements

The individual must be able to work the hours specified.
To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds.
Registered Nurse (RN) - Board of Nursing
An active license in the state of practice. Upon Hire
1-3 years Related professional experience.

Nice To Haves

4-6 years Related clinical experience and/or training
Knowledge of hospital revenue cycle and EMR.

Responsibilities

Reviews clinical documentation contained in the hospital electronic medical record for current admissions, continued stays and retrospective inpatient and observation level of care appropriateness.
Prompts admitting providers regarding missing, unclear, or conflicting clinical documentation in the EMR that does not support an inpatient admissions, when necessary.
Utilizes third party clinical guidelines for level of care reviews (first level review), and refers cases to the internal or external physician advisor for second-level determinations if documentation does not support the level of care ordered by the admitting provider.
To support admission, continued stay and retrospective reviews, reports relevant clinical information to approved third-party payers utilizing payers websites, fax machines, or via telephone communications if payer required the information.
Maintains accurate documentation of activities within the UR Module and various systems utilized to support the initiatives, maintains quality and production standards in accordance with internal guidelines/policies.
Maintains knowledge by payer for level of care requirements, inpatient only list, concurrent and retrospective authorization requirements, documentation requirements, non-covered services, or waiver requirements.
Serves as a Resource and provides subject matter expertise to providers, clinics, and the members of the organization as needed.
Assists leaders with activities such as payer trending, audits, and other tasks as assigned.
Responsible for coordination of payer Peer-to-Peer appeals for commercial/managed care payer admission/concurrent level of care denials.
Collaborates with the Clinical Appeals Specialist to ensure tracking and trending of all Utilization Review related denials/appeals are appropriately documented.
Assists with the collection and maintenance of records as needed by Compliance, Joint Commission, OSHA requirements or as may be required by law.