Utilization Review Coordinator RN

Summary

This position plays a pivotal role in maintaining the fiscal health of the organization by ensuring the organization is fully reimbursed. Educating and consulting with the physician and the health care team to ensure accuracy of medical necessity criteria and to ensure timely and appropriate level of care is achieved. This requires excellent time management and prioritization skills along with collaboration with the provider and case management teams.

Responsibilities

(30%)* Performs admission, concurrent and focused reviews using the medical necessity criteria and complies with CMS requirements. Perform admission/continued stay/discharge reviews when applicable.

(30%)* Determines necessity of second-level review and implement process per hospital policy. Provide educational information to physicians and other staff members as appropriate regarding medical necessity criteria, documentation guidelines, admission status, etc. and collaborates with the care team.

(15%)* Assist UR Committee and subcommittees in identifying areas of mis-utilization. Perform Hospital- wide quality assurance activities as requested.

(15%)* Facilitate appropriate insurance pre-certification, appropriate admission and status of patient.

Successfully negotiates patient status with the payer.

(10%)* Attend and participate in case management and discharge planning as required.

Other Duties And Responsibilities

Complete denial appeals with physician and additional chart information, coordinate information and send in appeal. Coordinate with Appeals RN, as needed.

Maintain documentation of reviews, telephone contacts, appeal activity and progress.

Provides pertinent clinical data to designated outside agencies to assure compliance with their requirements.

Participates in Continuous Quality Improvement as required by the Medical Center and the job description.

Is skilled in determining the need for and implementing the hospital notice of non coverage.

Understands and is accountable for the Health Systems customer service standards.

Certifications and Licensures

Credential:RN: Registered Nurse

Equivalent Experience

Qualification Source:

Essential: true

Required Education

Education: Associates Degree

Equivalent Experience: BSN Preferred

Education Specialization

Essential: true

Other Information

Experience, Training And Skills

Three to five years clinical experience.

Prior UR experience and/or certification in U/R or Case Management preferred.

Basic knowledge of coding preferred.

Physical/Mental Requirements And Typical Working Conditions

Exposure to stressful situations, including those involving public contact, as well as trauma, grief and death.

Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.

Overall vision and hearing are necessary with or without assisted device(s).

Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.

Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.

Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.

Physical Demand Level: Sedentary. Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.

Other Comments