Utilization Review Nurse - SJE - FT - Days
Catholic Health Initiatives 180 reviews - Lexington, KY

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Job Summary :

Responsible for Utilization Review for medical necessity and level of care for patients accessing services at St. Joseph Hospital and St. Joseph East, though the application of InterQual Criteria and other resources as necessary. Determines correct patient status and obtains order from admitting physician. Cooperates with outside vendor on Medicare/Medicaid Observation vs. Admission status . Communicates with commercial payers with demographic and clinical information as contract requires. Issues ABNs and HINNs as needed per CMS guidelines. Enters complete clinical and payer information into MIDAS system. Facilitates action plans regarding denial management for all payers. Performs other duties as instructed by Department Director and or Department Manager.

Essential Duties :
  • Reviews all preadmissions and admissions to observation and inpatient status within guidelines to assure criteria has been met for appropriate level of care.
  • Reviews all inpatient admissions concurrently (according to guidelines) until dismissal to assure continued stay and discharge criteria have been met.
  • Communicates effectively with the attending physician any questions concerning patient status.
  • Communicates with the Medical Staff and Nursing Staff any utilization issues concerning patient care activities.
  • Communicates with patients regarding their concerns, problems and/or understanding of their health insurance coverage.
  • Contacts the Utilization Review Chairman concurrently regarding any patient not meeting continued stay criteria and/or meeting discharge criteria but not being discharged.
  • Identifies preliminary (working) admission diagnosis to enable a tentative DRG and corresponding average length of stay to be assigned to each inpatient stay.
  • Presents Hospital Issued Notices of Non-coverage to patient/family and attending physician when patient’s stay will no longer be covered by Medicare.
  • Acts as liaison between Hospital, physicians, patients and Medicare/Medicaid/Insurance review staff.
  • Performs preadmission and continued stay preauthorization for patients identified by Admissions as required this service.
  • Adheres to Federal and State rules as outlined.
  • Prepares monthly reports for review by the Medical Staff.
  • Reviews all admissions to the swing bed unit to assure placement in appropriate level of care.
  • Updates and documents pertinent information regarding progress of the swing bed patient and assesses for continued appropriate level of care.
  • Coordinates patient status information with other Hospital departments, physicians, physician’s office staff, other acute care facilities and nursing facilities, as needed.
  • Prepares and/or assists with maintenance of timely registries as required by Federal and/or State law.
  • Maintains confidentiality of all information received while performing job duties.
  • Accesses Hospital computer system in accordance with Hospital and department policies.
  • Attends appropriate Hospital inservices and other educational inservices as needed and requested to remain updated on Federal, State, Hospital and/or Department policies and procedures.
  • Documents in accordance with current standards/policies.
  • Performs other job duties as assigned.
  • Interacts professionally with patient, family and other healthcare team members.
  • Demonstrates an ability to be flexible, organized and function under stressful situations.
  • Maintains a good working relationship both within the department and with other departments.
  • Adheres to dress code; appearance is neat and clean.
  • Reports to work on time and as scheduled.
  • Prioritizes tasks and completes work in a timely fashion.
  • Wears identification while on duty (including department keys).
  • Graduate of an accredited Registered Nursing Program .

  • 1 year UR experience or Case Management in a hospital or commercial insurance setting.
  • Experience with InterQual and UR. 3-5 years recent acute care experience preferred.

  • Licensure:
    • RN licensure in the state of practice.
    Additional Responsibilities :
    • Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times
    • Adheres to and exhibits our core values:
      Reverence : Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.
      Integrity : Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.
      Compassion : Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.
      Excellence : Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
    • Maintains confidentiality and protects sensitive data at all times
    • Adheres to organizational and department specific safety standards and guidelines
    • Works collaboratively and supports efforts of team members
    • Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community
    KentuckyOne Health and its organizations are Equal Opportunity Affirmative Action Employers CB\

    Job Medical/Surgical Services
    Primary Location KY-Lexington-Saint Joseph East

    Shift 10am-6:30pm
    Scheduled Hours per 2-week Pay Period 80
    Weekends Required Every Third
    Status Full Time

    About this company
    180 reviews
    For Catholic Health Initiatives (CHI), returning sick people to good health is more than a business -- it's a mission. Formed in 1996...