Complete utilization management functions for assigned patients as outlined in the Utilization Review Plan for Randolph Hospital. Review patient record and plan of care at admission or placement into observation utilizing the criteria set approved and adopted by the Medical Executive Committee. Facilitate any second level reviews for patients not meeting the criteria set for the assigned level of care. Conduct continued stay reviews on periodic basis to ensure level of care appropriateness. Identify outlier cases and refer for second level continued stay review. Timely notification of the admitting physician on any issues of status that need discussion and facilitation of changes required. Serve as resource to hospital staff and medical staff on issues related to utilization management and level of care decisions. Assist with case reviews for payer denials concurrently and retrospectively as needed. Facilitate insurance approval for services needed at discharge such as home health services, facility placement, oxygen or IV antibiotics, as requested by the RN Case Manager or Discharge Planning Case Manager. Graduate from an accredited school of nursing. BSN preferred. Current license to practice as a Registered Nurse in North Carolina required. Previous training in utilization management or case management preferred. Excellent assessment skills required. Excellent communication skills required. Ability to set priorities and work independently is required. Knowledge of treatment modalities and alternate healthcare delivery systems is preferred. Three years working experience in an acute care setting is required. Prior experience in medical/surgical nursing, critical care, emergency care or home health is preferred.
Randolph Hospital - 22 months ago