Utilization Review Care Manager, RN

Overview

Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, medical necessity standards, and Inter Qual guidelines. The Utilization Review Nurse utilizes clinical knowledge to support the coordination and documentation and communication of medical services and/or benefits. The Utilization Nurse also serves on the liaison between the physicians, patients, payers and care managers regarding termination of benefits, denial notification, and expedited appeals.

Has access to highly sensitive, confidential information.

• Evaluates medical records for appropriateness of admission status utilizing a combination of clinical information, screening criteria, and third party information. Collaborates with business office, care managers, attending physicians, and physician advisors as needed.
• Works with Patient Registration inancial Counselor(s) to identify correct insurance source and proper billing.
• Verifies patient admission information for each assigned patient within 24 hours of patient’s admission (next business day) or per payer guidelines.
• Collaborates with the Case Manager to identify referrals to Financial Counselors.
• Negotiates resolution of disagreements over the need for acute hospital level of care with the insurer.
• Educates staff and physicians about managed care principles, observation status, and reimbursement rules.
• Maintains records in a complete, detailed, and orderly manner.
• Identifies Potential Avoidable Days per department policy.
• Conducts self-auditing of medical records for status accuracy and provides peer consultation regarding cases in which patients are failing to progress and/or experiencing significant deviation from the plan of care.
• Collaborates with case managers and social workers for patients with complex, clinical, financial and psycho-social needs.
• Reviews physician orders and patient progression and intervenes with care coordination as needed. Collaborates with other departments to eliminate barriers, as necessary.
• Builds trusting relationships with attending physician, patient and/or family and other members of the healthcare team. Establishes a caring relationship with patients and their caregivers, promotes patient engagement and guides patients/families through the transition phase
• Gathers information for statistical monitors, plus special projects within the Care Management Department.
• Updates and documents in Expanse and Cortex, pertinent clinical information by utilizing screening criteria and assigns next review date.
• Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS) and reduction of avoidable readmissions.
• Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians.
• Identifies and reports Quality and Risk Management concerns and enters risk events in Midas.
• Is knowledgeable of hospital mission, vision, and values and performs in a manner to support them.
• Reviews an average of 25 patients per day.
• Delivers denial letters from all payers to the beneficiary or proper representative; explain appeal rights.
• Must be able to successfully complete the Interrater Reliability Tool for Inter Qual Level of Care Acute Criteria. (Adult and Pediatric) after successful orientation.

• 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 Registered Nurse with current Alabama license.
• Minimum 2 years experience as an RN preferred.
• Minimum of at least 2 years as care management and/or utilization management experience…