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Job Description Summary:

Job Description:

The Utilization Review RN performs activities which support the Utilization Management functions. They are responsible for the delivery of the Utilization Management process including but not limited to: making clinical recommendations regarding medical necessity for admission and continues stay screens patients for client specific guidelines regarding insurance Medicare and/or Medicaid guidelines send payor specific Notice of Admission and continued stay reviews. The employee communicates with physician and case managers regarding payor approval/denial of admission and continues stay review. They process payor denials and retro reviews promote optimal health care outcomes in accordance with the policies procedures applicable laws and contracts philosophy mission and values of UofL Health assumes responsibility and accountability for the appropriate utilization of facilities and services and serves as a resource to physicians. The employee conducts admission and concurrent reviews including observation and inpatients identifies patients who do not meet criteria and takes action to ensure patients are cared for in the most appropriate level of care; coordinates care in conjunction with other members of the interdisciplinary healthcare team to provide and facilitate optimal health and financial accountability. This employee utilizes the nursing process (assess plan implement and evaluate) and management process (plan organize direct and control) to provide a framework for decision-making; maintains confidentiality of information; actively supports organizational goals and objectives by providing needed information to divisions and departments.

Essential Functions:
Promotes optimal management of clinical resources by conducting timely admission and concurrent utilization review for all patients of designated medical services; certifies medical necessity for admission continued stay and discharge reviews for patients certified by utilizing the current MCG criteria; documents clinical information in Case Management Software system
During the concurrent review process evaluates the medical record to identify any process delay impacting the timeliness of patient care in a collaborative effort to ensure that the appropriate resources are utilized (i.e. physical therapy cardiac rehabilitation or nutritional service)
Supports the utilization review program by maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers
Communicates closely with third party payors to ensure all pertinent clinical information is provided to secure an authorization; appropriately documents information regarding the authorization number and the approved length of stay on the Case Manager Software
Advocates for patient/family needs in a respectful non-judgmental and confidential manner
Serves as a resource to physicians for clinical management and financial issues; assists the providers with promoting efficiencies in the care delivery system and reducing/ eliminating barriers to efficient/effective servic
Reviews patient cases for potential problems with OIG Workplan Audits and compliance issues; reports problems and makes recommendation to appropriate departments
Appropriately refers cases to manager/director of care coordination CAO or medical director when intensity of service or severity of illness is not present and is unable to resolved
Educates physicians patients and staff with regards to payors financial issues documentation and potential compliance issues
Investigates and responds to billing concerns from Business Office Health Information Management Admitting and other sources; resolves financial and billing problems such as appropriate patient status correct payor source denials appeals and system issues
Other Functions:
Develops a cooperative assistive relationship with third-party reviewers working to facilitate timely positive responses for patient accounts
Attends Monthly Departmental Staff Communications Meetings. Serves as an active member of committees as needed which may include a variety of projects or topics
Enhances professional growth and development through participation in educational programs reading current literature attending in-service meetings and workshops that are related to assigned areas of responsibility.
Maintains compliance with all company policies procedures and standards of conduct
Complies with HIPAA privacy and security requirements to maintain confidentiality at all times
Performs other duties as assigned

Additional Job Description:

Education:
Bachelor of Science in Nursing (required)
o An RN with a bachelors degree in Business Health Care Administration or equivalent on the condition that they enroll in a BSN program within one year of employment and complete the BSN within three years of employment
Experience:
Two (2) years experience as an RN (required)
Additional (1) year experience in case management/utilization management (preferred)
Three years experience with Behavior Health experience (required for positions at Peace Hospital)

Licensure:
Active Kentucky Registered Nurse License or compact license with privileges to work in Kentucky
Certification:
Case Management Certification (ACM ANCC-Nurse Case Manager or CCM) preferred