Utilization Review - Registered Nurse (Weekend)

The Utilization Review RN will perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Collaborates with UM Specialists, Physician Advisor, and various departments regarding medical necessity of hospital stays from admission authorizations to discharge, including denials and appeals. Strong communication skills are necessary to access available resources and communicate with providers and other members of the interdisciplinary team. Active participation in program development and process improvement efforts is an expectation.

• Conducts inpatient admission, concurrent, and retrospective review for Medicare and Medicaid beneficiaries as well as managed care and self-pay patients based on CMS guidelines.
• Uses national medical necessity tool to screen for appropriateness for inpatient level of care or observation services based on physician certification including history and physical, treatment plan, potential risks, and basis for expectation of a 2-midnight stay.
• Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services.
• Consistently identifies and records information on any progression-of-care/patient flow barrier and communicates with care team as necessary to notify of denial of continued stay so team can impact barriers.
• Collaborates with physicians and APRNs to influence appropriate utilization of resources, accurate status determination, and transitions of care. Educates members of the patient’s care team on the appropriate access to and use of various levels of care.
• Represents utilization management at various committees, professional organizations, and physician groups as needed.
• Promotes medical documentation that accurately reflects findings and interventions, presence of complications or comorbidities, quality and safety indicators, and patient’s need for continuing stay.
• Confers with attending physician and Physician Advisor if medically unnecessary inpatient treatment is contemplated. Coordinates appeals to denials as necessary.
• Serves as a resource person to physicians, nurses, billing office and other external departments for coverage and compliance issues.
• Other duties as assigned

Education

• Bachelor's Degree - Graduate from school of nursing. - Required
• Bachelor's Degree - BSN - Preferred

Work Experience

• 3 Years - Clinical or managed care experience - Required
• Knowledge of medical necessity guidelines - Preferred

Licenses and Certifications

• Registered Nurse (RN) - State Licensure/Or Compact State Licensure - Licensed in state of Missouri - Required Upon Hire

Travel Requirements

• Must be able to travel between various system facilities and off-site locations as needed. - Required

Skills and Abilities

Essential Technical/Motor Skills

• Hand/eye coordination; speaks clearly; good hearing; computer skills/telephone skills and voice recorder skills.
• Ability to read, write, and speak clearly.

Interpersonal Skills

• Must be able to teach, provide accurate and concise information, answer questions, demonstrate excellent leadership skills, maintain positive relationships with multiple customers, motivate and persuade others.

Essential Physical Requirements

• Physical requirements include standing, walking, and fine motor skills; reaching for items; bend, squat, sit, and climb stairs.
• Sufficient strength and mobility to sit for long periods of time (depending on assignment).

Essential Mental Abilities

• Critical thinking skills, problem-solving skills, negotiating abilities.
• Capable of determining appropriate response to emergency situations.
• Ability to focus and concentrate in order to correctly perform tasks despite numerous distractions and interruptions.
• Ability to maintain professional demeanor to communicate and interact with patients, customers and team members.

Essential Sensory Requirements

• Appropriate functional vision, hearing acuity.

Exposure to Hazards

• Eye and neck strain.

Other Skills and Abilities