Utilization Review RN Utilization Resource Management Pennington NJ

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization.

As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$39.40 - $59.19

Scheduled Weekly

Hours:

40

* Note - This is not a remote position*

SUMMARY (Basic Purpose of the Job) Performs a variety of utilization and resource management activities to promote quality, clinical and cost effective outcomes. Assesses patients treatment plans, communicates to third party payers, and collaborates with healthcare team members. Performs functions which help to optimize lengths of stay, utilize resources efficiently, and promote cost effective practices without negatively impacting patient care. Adheres to established standards, practices and procedures.

Education:

Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred.

Experience:

Five years of clinical nursing and three years quality management, utilization review or discharge planning experience.

Other Credentials:
Registered Nurse - NJ

Knowledge and

Skills:

Five years of clinical nursing or three years quality management, utilization review or discharge planning experience. CPHQ, CCM, ACM or CPUR preferred.

Special Training:
Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines.

Mental, Behavioral and Emotional Abilities:
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Usual Work Day: 8 Hours

Does this position formally supervise employees? No

If set to YES, then this location has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

• Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care.
• Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination.
• Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee.
  
  Identifies, develops and implements strategies to reduce length of stay and resource consumption.
• Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry.
• Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians.
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters.
• Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program.
• Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels.
• Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources.
• Recognizes and responds appropriately to patient safety and risk factors.
• Represents Utilization Management at various committees,…