The work involves performing professional and non-professional nursing duties in connection with the Utilization Review Process at the Erie County Medical Center Corporation. The incumbent assesses, monitors and facilitates healthcare services and needs throughout the patient experience to optimize outcomes. The work is performed under the general direction of the Utilization Management Coordinator or higher level Utilization Review Manager. Supervision is not a function of this position. Does related work as required.
TYPICAL WORK ACTIVITIES:
Facilitates a process of assessment, planning and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost effective care;
Validates appropriate level of care (severity of illness), efficient and effective care delivery (intensity of services) and safe discharge to the next appropriate level of care;
Conducts admission and concurrent review using current evidence-based clinical decision support criteria;
Completes full assessment of plan of care to determine if criteria are met to ensure third party reimbursement;
Enters data into utilization data base;
Conducts clinical chart reviews; gathers clinical information to assess and expedite care needs;
Discusses cases with treating physician(s) and other healthcare professional to better understand plans-of-care;
Identifies and evaluates delays in care;
Initiates a discharge planning and readmission prevention plan when applicable;
Approves bed days for inpatient cases when applicable;
Arranges for alternative care services such as acute long-term care, acute rehabilitation or skilled nursing to move patients through the care continuum;
Completes all requirements relative to new Alternant Level of Care orders, admissions and denials;
Completes Patient Review Instrument (PRI) prior to admission as needed;
Maintains appropriate documentation;
Consults with the Medical Director and treating physician(s) as needed to troubleshoot difficult or complex cases;
Contacts third party payers with initial and concurrent reviews to obtain authorization for hospital stay;
Participates in staff meetings.
FULL PERFORMANCE KNOWLEDGE, SKILLS, ABILITITES AND PERSONAL CHARACTERISTICS: Thorough knowledge of utilization review concepts, resource management and reimbursement methodologies; thorough knowledge of Federal and State regulations as they relate to hospital utilization review; good knowledge of medical terminology related to patient charts; good knowledge of Patient Review Instrument (PRI); good knowledge of clinical decision support criteria; good knowledge of billing procedures and hospital insurance procedures; ability to identify and resolve utilization issues; ability to prepare reports and statistics of hospital utilization; ability to establish and maintain effective working relationships; ability to communicate effectively both orally and in writing; sound professional judgment; initiative; proficient in the use of Microsoft applications;; physically capable of performing the essential functions of the position with or without reasonable accommodation.
A) Graduation from a regionally accredited or New York State registered college or university with a Bachelor’s Degree in Nursing, Health Administration, Human Service or a closely related field and five (5) years of behavioral health and/or medical/surgical registered nursing experience; or:
B) Graduation from a regionally accredited or New York State registered college or university with an Associate’s Degree in Nursing, Health Administration, Human Services or a closely related field and seven (7) years of behavioral health or medical/surgical registered nursing experience.
C) An equivalent combination of training and experience as set by the limits of (A) and (B).
Possession of a license and current registration to practice as a Registered Professional Nurse in the State of New York at time of appointment; and:
Possession of a Certification as a Patient Review Instrument (PRI) Assessor as issued by the New York State Department of Health at the time of permanent appointment.
Erie County Medical Center - 21 months ago