PRN RN Utilization Review

St. Elizabeth Healthcare•Edgewood, KY

About The Position

Engage with us for your next career opportunity. Right Here. At St. Elizabeth Healthcare, every role supports our mission to provide comprehensive and compassionate care to the communities we serve. For more than 160 years, St. Elizabeth Healthcare has been a trusted provider of quality care across Kentucky, Indiana, and Ohio. We’re guided by our mission to improve the health of the communities we serve and by our values of excellence, integrity, compassion, and teamwork. Our associates are the heart of everything we do. The Utilization Management Nurse identifies, abstracts, and relays information from the patient’s medical record necessary to manage resource utilization in efforts to obtain payer authorization for acute care services rendered to patients. Primary duties include: thorough chart reviews to determine correct patient class, documents patient class and clinical review information utilizing standard medical necessity criteria for third party payors, aggressive concurrent denial management, Condition Code 44 management, Observation patient management, serves Notices of Non-Coverage/ABNs when appropriate, documents risk management and quality concerns appropriately. Demonstrate respect, dignity, kindness and empathy in each encounter with all patients, families, visitors and other employees regardless of cultural background.

Requirements

RN, Licensed to practice nursing in the state where work is being performed.
Knowledge and ability in resource utilization concepts and systems.
Knowledge and ability in quality improvement concepts and systems.
Typing and computer entry skills.
6 months experience in nursing specialty areas.

Responsibilities

Collects utilization information through observation, chart review and dialogue.
Accurately records clinical information in data systems as appropriate (e.g., InterQual).
Assigns patients to most appropriate care level, considering both InterQual and payer guidelines, and secures a physician care level order for same.
Monitors and works accounts on Epic workqueues to assist in securing authorization for payment.
Monitors and proactively manages all concurrent denials and payer requests for change in level of care orders.
Communicates chart review information to the healthcare team as well as the third party payers to promote effective and efficient utilization of resources.
Understands behaviors, conditions and communications consistent with the age-related needs of the patient population reviewed per standardized medical necessity guidelines.
Observes Department needs through own assignment assessment, budgeting time to allow for timely work completion as well as extra departmental special studies as needed.
Establishes priorities in planning/coordinating daily assignments.
Orients new employees to department in specific job role(s) as appropriate.
Identifies and documents risk management, quality and infection control issues and communicates to appropriate departments/services.
Performs other duties as assigned.