Registered Nurse-Utilization Management-Full Time, Days

Cape Fear Valley Health

2d•Onsite

About The Position

Responsible for performing the initial and concurrent Utilization Review determination on all patients admitted or placed in observation (Outpatient with Observation Services). Direct discussion with the physicians and advanced practice providers to determine medical necessity for admission and establish appropriate status and level of care requirements. Facilitates clinical guidelines and achievement of desired treatment outcomes in the most appropriate setting and the most cost-effective manner. Analyzes patient records to determine appropriateness of admission, treatment, and length of stay in a health care facility to comply with regulatory and payor reimbursement policies. Maintain compliance with regulatory changes affecting utilization management and performs utilization review in accordance with all state and federally mandated regulations. Works collaboratively with the Utilization Management Manager and payors to ensure that denials and appeals are tracked and responded to in a timely and appropriate manner.

Requirements

Associate’s degree in nursing required
Registered Nurse with active North Carolina License or Compact State Licensure preferred
3 years’ experience in Acute Care Setting preferred
Medical/Surgical and/or ICU experience preferred
Critical thinking and clinical competence demonstrated at an above average level
Excellent interpersonal communication and negotiation skills
Self-motivated, proven written, telephonic, and electronic communication skills, assertive and persuasive in interactions with customers, peers, management, and core staff served
Ability to discuss a patient’s clinical, socio-economic, and financial issues with physicians and patient and/or patient representatives
Strong organizational and time management skills
Proficiency with various computer programs, including Microsoft Office, Allscripts, InterQual, Valley Link, eHIM, Teletracking, Form Fast and SMS
Ability to transition to EPIC system, for Utilization Management processes.
Ability to be flexible, open-minded, and adaptable to change
Ability to analyze related information, plan effective actions and follow through reliably
Ability to work collaboratively with department staff, physicians, and healthcare professionals at all levels to achieve established goals
Some light carrying and lifting may be required
Near visual acuity to proofread hand and typewritten materials
Manual ability to use telephones and computer keyboards
Position involves sitting for extended periods of time performing data entry into the computer
Must be able to lift 35 pounds
RN - Board Of Nursing

Nice To Haves

Bachelor’s degree in nursing preferred
Professional certification in Case Management or Utilization Management preferred
Case Management experience preferred
Additional one year in managed care claims/reimbursement or other healthcare field preferred

Responsibilities

Performs initial admission reviews on all patients within one day of bedding, using the appropriate InterQual guidelines or in accordance with CMS rules and regulations for admission and medical necessity
Reviews physician orders for level of care status against patient status in the hospital registration system to ensure accuracy
Ensures the chart coincides with the review or CMS rules and regulations for appropriate level of care and status on all patients
Adheres to Medicare Condition Code 44 process
Issues Medicare Outpatient Observation Notice (MOON) promptly to ensure timely notification to patients
Coordinates with registration/bed placement departments and physician’s office to assure pre-certification authorizations and supporting documents are obtained when required
Reviews patient medical records for third party payors and provides clinical information to support admission and continued stay review
Send billing communication to the designated PFS and HIM team members to ensure accurate billing designation
Assesses and evaluates the medical necessity and appropriateness of ancillary testing, medications, treatment, and plan of care, discussing concerns with the involved case manager
Representative and point of contact for the Medicare Appeal process
Adheres to mandates, standards and policies and procedures as determined at the federal, state, health system and department level
Promotes positive customer service and service orientation in the performance of position duties and responsibilities and interactions with patients, hospital staff and visitors
Participate in quality improvement activities in the direction of the Leadership Team to improve processes and promote evidence-based practice
Other duties as assigned