RN (Utilization Review)

Sarah Bush Lincoln•Mattoon, IL

1d•$66,768 - $103,501

About The Position

Utilization Review RN conducts medical certification review for medical necessity for acute care facility and services Uses nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation improvement opportunities. Relays information as requested to the payer sources. Assures the highest quality, most cost effective patient care in the most appropriate setting.

Requirements

ADN (Required)
RN-Registered Nurse - Illinois Department of Financial and Professional Regulation

Responsibilities

Assessment - Collects pertinent data and information relative to the patient's health or the situation. Recognizes normal and abnormal findings when gathering data.
Assumes responsibility for remaining current on all regulatory and reimbursement rules and regulations.
Concurrently reviews medical necessity, bed status, length of stay and quality of care indicators on all assigned patients. Serves as coordinator for communication with payors and providers to determine the appropriateness of hospital level of care.
Confers with attending physician and physician advisor if medically unnecessary inpatient treatment is contemplated.
Consults with medical staff, care team, and case managers as necessary to resolve immediate progression-of-care barriers through appropriate administrative and medical channels.
Coordinates Medicare appeals with the discharge planner, Director of Utilization Management, Physician Advisor and the QIO.
Coordination of Care - Plans and evaluates care in collaboration with appropriate disciplines.
Diagnosis - Analyzes assessment data to determine actual or potential diagnosis, problems, and issues.
Evaluation - Evaluates progress toward attainment of goals and outcomes. Reports data and outcomes to others as appropriate.
Implementation - Implements care or work plan in alignment with the plan and approved safety, infection control, and department/organization standards.
Knowledge - In collaboration with leaders, actively pursues required knowledge and skills through orientation activities specific to the position, reading current literature and seeking new learning opportunities.
Outcomes Identification - Identifies expected outcomes for a plan individualized to the patient or situations.
Planning - Develops a plan that prescribes strategies to attain expected, measurable outcomes.
Recognizes and responds appropriately to patient safety/risk factors.
Refers all denials, as appropriate, to the Director of Utilization Management and/or Physician Advisor.
Relationships - Establishes effective working relationships with peers, physicians, and other members of the health care / work team. Identifies and confers with appropriate resources regarding patient / work decisions.
Reviews operating room (OR) schedule 48 hours in advance of scheduled procedures to confirm that all eligible Medicare and Medicaid admissions were identified and the coded procedure is or is not on the Medicare inpatient-only list. Confirms that physician’s admission orders accurately reflect status.
Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
Serves as coordinator for third party payer reviews, certifications and authorizations.
Teaching - Employs teaching strategies to promote health and a safe environment.
Works closely with physician advisor to review resource utilization data and trends to identify outliers who may benefit from real-time coaching to improve outcomes.