Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information and InterQual guidelines. The Utilization Review Nurse utilizes clinical skills to support the coordination and documentation and communication of medical services and/or benefit Administration determinations. Collect information, to render appropriate medical necessity, benefit determinations. Identify patients for referral opportunity to integrate with other product services and programs. The Utilization Nurse also serves on the liaison between the Physicians, patients, payers and Case Managers regarding termination of payment, denial notification and expedited appeals.
KEY RESPONSIBILITIES / ESSENTIAL FUNCTIONS
Analyzes each of the assigned medical records for the purpose of admission and concurrent review using screening criteria.
Works with Patient Registration\Financial Counselor (s) to identify correct insurance source.
Provides clinical information as necessary to obtain authorization for acute inpatient care.
Monitors the utilization of observation services and collaborates with the Case Manager regarding correct status.
Verifies patient admission information for each assigned patient within 24 hours of patient's admission (next business day).
Collaborates with the Case Manager to determine patient's appropriateness for acute hospital level of care.
Monitors patient's clinical course to verify patients continued need for acute hospital level of care.
Provides third party payers with concurrent review information as needed to comply with payers' requirements for documentation of medical necessity.
Negotiates resolution disagreements over the need for acute hospital level of care with the insurer.
Intervenes with appropriate parties regarding inappropriate admissions, delays in discharge and the over-utilization of hospital resources.
Refers appropriately to Performance Improvement and Risk Management for patient safety occurrences and sentinel events.
Refers cases not meeting acute inpatient criteria to a physician advisor and assists with his/her review of the case.
Delivers denial letters from all payers to the beneficiary or proper representative; explain appeal rights.
Monitors adequate documentation by physicians in order to justify admission and continued stay criteria.
Gathers information for statistical monitors, plus special projects within the Case Management Department.
Updates and documents in the Case Management system pertinent clinical information by utilizing screening criteria and assigns next review date.
Maintains records in a complete, detailed, and orderly manner.
Identifies Potential Avoidable Days per department policy.
Collaborates with the Case Manager to identify referrals to Financial Counselors.
Is available to potentially serve in rotation as department team facilitator.
Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS).
Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians.
Is knowledgeable of hospital mission,, vision, and values and performs in a manner to support them.
Identifies and reports Quality and Risk Management concerns.
Demonstrates Age Specific competency in managing assigned cases.
Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation
Once qualified, must be able to successfully complete the Interrator Reliability Tool for InterQual Level of Care Acute Criteria (Adult and Pediatric).
MINIMUM KNOWLEDGE, SKILLS, EXPERIENCE REQUIRED
- Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
- Performs compliance requirements as outlined in the Employee Handbook
- Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
- Requires use of electronic mail, time and attendance software, learning management software and intranet.
- Must adhere to all DCH Health System policies and procedures.
- All other duties as assigned.
Anyone hired after July , 2011 must meet the following:
Minimum of Licensed Practical Nurse with current Alabama license.
Minimum of 3 years of Med Surgical experience required; Utilization Review experience preferred.
Efficient use of basic computer skills with the ability to type 20 words per minute required, effective July 1, 2011.
Very good organizational and interpersonal skills required. .
Ability to multi task, prioritize and effectively adapt to a fast paced changing environment
Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the phone and typing on the computer.
Work requires the ability to perform close inspection of computer generated documents as well as a PC monitor.
Typical office working environment with productivity and quality expectations.
Ability to establish priorities, meets deadlines, and maintains proper productivity.
Ability to form positive, collaborative relationships with hospital staff, patients, families and payers.
Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.
Ability to effectively negotiate with internal and external providers of patient care services.
Ability to develop leadership skills and to serve as a role model for clinical staff.
Ability to lead and actively participate in multidisciplinary teams.
Ability to work independently or within a team structure.
Excellent interpersonal skills and communication style.
Must be able to read, write legibly, speak, and comprehend English.
Is able to lift at least 20 lbs.
Ability to tolerate prolonged periods of sitting, or standing and/or walking.
Ability to reach reasonable distances to handle equipment.
Good manual and finger dexterity.
Good communication skills
Physical presence onsite is essential. Hearing and vision must be normal or corrected to within normal range.
Able to perform the duties with or without reasonable accommodation.
As a community-owned, not-for-profit organization, DCH Health System is committed to providing quality health care services to all residents...