UTILIZATION REVIEW NURSE RN

FLSA Status

Exempt

#EXPRN

Job Role Summary

Essential Functions and Responsibilities

• Work behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensure that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays
• Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process
• Ensuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standards
• Responsible for managing each patient's plan of care, monitoring for appropriate resource utilization, and collaborating with the inpatient team as well as outpatient providers to coordinate the patient's transition plan of care
• Serves as a patient advocate, ensuring that efficient health care is provided. The role is to provide primary nurse support through all aspects of utilization management across the continuum of care and is not limited to the initial review process
• Assesses degree of medical necessity for any patient seen in the Emergency Department and perform Utilization Review using the Eskenazi Health approved clinical decision support criteria
• Reviews patients' admissions for appropriateness and type. Refers case to Medical Director and/or Department leadership for review when case fails to meet admission standards
• Coordinates the most accurate and appropriate patient status for care
• Identifies strategies to reduce the length of stay and resource consumption within the appropriate length of stay
• Assesses patient's health status through collection of information from EMR, interview any other relevant sources to collect specific information in an attempt to provide the necessary determination for patient's status for appropriate medical regimen
• Track readmissions and Emergency Department visits for patients assigned
• Completes an admission review even when the patient under assessment has been relocated to an admitted or observation bed
• Collaborates with Emergency Physicians and Attending Physicians to ensure that patients meet criteria for Admission, Placement on Observation Status or neither
• Oversees the initial admission review, utilizing criteria, within 24-48 hours of the patient's admission to the hospital to ensure appropriateness of the assigned level of care and timely implementation of the treatment plan
• Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation
• Communicate with the Inpatient Case Manager to ensure appropriate status and level of care for patient, and that transition plan is implemented with determined goals in mind
• Communicates with Payor Specialist for UR/UM to ensure proper status change and accurate billing practices
• Evaluatesthe active funding for each patient and communicates with Inpatient Case Manager/Social Worker to facilitate initiation of appropriate funding applications
• Demonstrates knowledge of levels of care of Inpatient and Outpatient status
• Ensures that transitions to post-acute services such as Acute Rehabilitation Centers is appropriate and streamlined, and home care services, as well as durable medical equipment is appropriately utilized
• Ensure the need for any services not provided at Eskenazi Health is evaluated and appropriate authorization is given and documented

Job Requirements

• Current Indiana nursing license required
• Minimum of 4 years clinical nursing experience required

Knowledge, Skills & Abilities

• Must demonstrate knowledge of the Utilization Management managed care processes
• Competency in the following areas required:
  • interpersonal, written/verbal communication, and negotiation skills
  • diplomacy, flexibility, and professionalism
  • cohesive networking with the Interdisciplinary Team