Utilization Review Specialist

The Utilization Review Specialist nurse (UR RN) is responsible for monitoring adherence to the Utilization Review Plan (UR Plan) to ensure the effective and efficient use of hospital resources and services and to monitor the appropriateness of hospital admissions and continued stay. The individual in this position will be required to fully understand the purpose and operation of Care Management and Utilization Review along with having the ability to make decisions based on sound judgment when a situation dictates. ESSENTIAL FUNCTIONS Ensures appropriate resource utilization relevant to financial regulatory and clinical aspects of care identifying any problems to effect timely resolution. Monitor trends/patterns of over/under utilization of hospital resources (i.e. avoidable days and utilization of diagnostics unrelated to diagnosis). Reviews expected length of stay (GMLOS) and anticipated discharge day appropriate for the patient s diagnosis with Care Managers and Agency Affiliated Counselor/ Social Worker. Performs concurrent reviews for patients to ensure that extended stays are medically necessary and that documentation supports continued stay. Is accountable for communication with Care Management Assistant and payers for continued stay authorization. Conducts medical necessity reviews according to the UR Plan. First level medical necessity reviews are conducted using InterQual criteria. Determines medical necessity and appropriateness of admission continued stay and level of care using a combination of clinical criteria (InterQual) clinical information and third party information. Communicates payer expectations to the team and collaboratively coordinates planning and documentation to satisfy provider and payer expectations. All cases that do not meet medical criteria for admission will be referred to Physician Advisor for secondary medical review. Assists the Utilization Management Committee in the assessment and solution of identified utilization review problems. Collaborates with third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent denials where possible. Communicates collaboratively with the Denial Management team and Physician Advisor regarding denied claims in an effort to overturn the denial. Helps identify those patients at risk for readmission. Partners with providers to assure that patients are assigned to the most appropriate level of care within the hospital and are transitioned to the appropriate level of care throughout episode of care. Maintains professional growth and development through the ACMA Compass continuing education program as assigned seminars workshops and professional affiliations to keep abreast of latest trends in field of expertise. 14. Ensures no injuries to self or others by following safe work practices and policies. This includes but is not limited to: security and safety understanding of MSDS equipment infection control fire disaster safe lifting and body mechanics. 15. Ensures self-compliance with organization policies and procedures as well as labor agreements. 16. Ensures the interface with team members and other support groups is conducted in a courteous and efficient manner conducive with the organization s values. 17. Conducts self in a professional manner and ensures personal appearance meets the standards necessary to perform the job function while representing the organization. 18. Ensures that additional accountabilities as may be required by management be handled in a manner necessary to meet organizational standards. WORK ENVIRONMENT The individual in this position reports to the Director of Care Transitions. This position works closely with Agency Affiliated Counselors Care Managers Medical Staff all Nursing Departments and Financial Access Specialists. EDUCATION & EXPERIENCE Education: a. Graduate of an accredited school of nursing. Bachelor s Degree preferred or equivalent combination of education and experience. License: a. Current Washington State RN Licensure. Certification: a. HCP (Healthcare Provider) Level of BLS (Basic Life Support) within three (3) months of hire. Experience: a. Three (3) to five (5) years acute care clinical nursing experience. Experience in a variety of acute care nursing departments preferred. b. One (1) year Utilization Management/Case Management experience Skills/Competencies: a. Flexible positive and clear interpersonal and communication skills with the ability to provide information in a collaborative manner with physicians and other staff. Must be able to communicate effectively in one-on-one situations as well as large group settings. b. Critical reasoning skills in clinical decision-making problem solving and ability to interpret and analyze data. c. Knowledge and understanding of regulatory financial and clinical aspects of care. d. Proficient in Microsoft Word and Excel and overall computer literacy required. e. Demonstrates competency on equipment listed on department specific checklist. f. Critical thinking skills: Seeks resources for direction when necessary. Performs independent problem solving. Decision-making is logical and deliberate. g. Performs actions that demonstrate accountability. Exercises safe judgment in decision-making. Practices within legal and ethical guidelines. h. Demonstrates competency in ability to care for customers/patients across the age continuum. PHYSICAL REQUIREMENTS Occasional or prolonged standing walking lifting reaching kneeling bending stooping crouching pushing and pulling Manual dexterity light physical effort ability to lift/carry up to 20 lbs. Good reading eyesight. Ability to communicate using verbal and/or written skills for accurate exchange of information with physicians nurses health care professionals patients and/or family and the public. Schedule: Monday Friday 7:00am to 3:30pm No holidays or weekends required (Dec 24 25 and Jan 1 off) On-site required Must be proficient in in both EPIC and InterQual programs

Shift: Day

Specialty Type: Nursing

Sub Specialties: Utilization Review RN

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