Utilization Review Nurse
Indian River Medical Center 3.566 reviews - Vero Beach, FL

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Indian River Medical Center is a 335-bed, not-for-profit hospital in Vero Beach, Fl. The hospital campus and facilities occupy more than 128 acres; its healthcare professionals include more than 250 affiliated physicians representing 41 specialties. IRMC is accredited by the Joint Commission and has been voted best places to work for the last 3 years. We are committed to training and education, not only to develop our staff to provide the best care possible to our patients.

Indian River medical Center is currently looking for a Utilization Review Nurse. This posting is for varied shift sboth 2 p - 10 p and 10 p - 2 am

Job Summary :
Responsible for coordinating and conducting medical necessity reviews for all Medicare, Medicaid, self pay and all other payers, upon admission and concurrently throughout the inpatient admission. Responsible for the accurate and timely entry of information related to coordination of reviews into AS400, MIDAS, and all other appropriate systems.

This position is also responsible for the verification of orders in the medical records in compliance with guidelines for determining level of care, coordinating with IRMC medical staff to reconcile and clarify orders as needed. She/he is directly responsible to the Utilization Review Manager. Maintains utilization review standards, procedures and functions in accordance with the Clinical Resource Management Plan

Major Responsibilities: .

  • Reviews medical record for appropriate application of medical necessity criteria to determine the appropriateness of admission or continued stay using Interqual criteria and clinical expertise.
  • Maintains effective & collaborative communication with all health care team members related to utilization & resource management issues. Acts as an educational resource and provides consultation to hospital medical personnel regarding medical necessity review processes and regulatory guidelines.
  • Provides concurrent review and follow-up with appropriate personnel regarding denials.
  • Collects, documents, analyzes and reports data for resource utilization, compliance, quality improvement and other areas as assigned.
  • Facilitates by documentation to improve process and compliance in the appropriate use of health care resources.
  • Develops & maintains positive relationships with customers both internal and external to IRMC.
  • Supports CMS Important Message Compliance Program to include appropriate delivery of the Important Message (IM) from Medicare Discharge/Appeal Notice to patients and/or healthcare surrogates, providing availability to answer questions, as needed.
  • Screen, analyze and coordinate pre-admission or upon admission the appropriate site of service for procedures identified by CMS as areas of focus or concern.
  • (i.e. procedures identified by Recovery Audit Contractors, the Office of the Inspector General or the applicable U.S. Attorneys Office, such as kyphoplasty, placement of pace makers.
  • Assure that financial counselors meet with self-pay patients to determine existence of third party payer source or assist with development of self pay strategies.
  • Accepts telephone, fax and electronic requests for clinical information and responds in a timely manner, providing necessary demographic & clinical information to facilitate certification of inpatient stay and procedures performed. Also responsible for retrospective submission of patient information as indicated.
  • Appropriately consults physician advisor (i.e. CMO) for support in application of medical necessity guidelines for admissions & continued stay when attending or consulting physicians demonstrate unresolved conflict with hospital policy/ criteria.
  • Attends in-services and is compliant with essential education without prompting from manager.
  • Performs other duties as assigned.

  • The Utilization Review Nurse would be required to have:

  • Current licensure as Registered Nurse in the State of Florida.
  • Associates Degree from accredited nursing program, Baccalaureate Degree in Nursing preferred.
  • Minimum of three years recent acute clinical experience or related healthcare experience preferred. Previous Interqual based criteria and/or medical necessity review experience preferred.
  • Basic computer skills, including ability to use computer keyboard and mouse.

  • Indian River Medical Center is an Equal Opportunity Employer who adheres to all federal, state, and local laws. In compliance with the American With Disabilities Act, IRMC, does not discriminate against qualified individuals with a disability. The hospital will select the best-qualified individual on the basis of ability, experience, education, and training as related to the requirements of the specific position for which the applicant is being considered.

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