Registered Nurse - Utilization Review (Per Diem)

Beth Israel Lahey Health•Burlington, VT

4d•$38 - $98

About The Position

The Utilization Analyst works with physicians, the payers and inpatient case management team to validate the medical necessity of the hospital care. Using the concepts of utilization review, clinical documentation improvement and revenue integrity, these specialized case managers analyze medical documentation to ensure that proper reimbursement will be achieved in coordination to the intensity of medical care provided.

Requirements

RN license
At least 5 years inpatient UR/CM experience
Knowledge of payment methodologies
Knowledge of federal and state regulations
Organization skills
Communication skills

Nice To Haves

Bachelor’s degree
RN with CDIP, CCM, ACM

Responsibilities

Completes initial reviews of patient records within 24–48 hours of admission: evaluate documentation to evaluate medical necessity of the hospital care.
Conducts follow-up reviews of patients daily in accordance with payer requirements.
Speaks with Attending physicians regarding status determinations and/or supportive documentation.
Educates physicians and key healthcare providers regarding the need for accurate and complete documentation in the medical record in correlation with the correct level of care.
Collaborates with case managers, nursing staff, coding team, the physicians and finance on relevant issues.
Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
Reviews external (i.e. PEPPER) and internal data (i.e. outliers) to trend, track and educate to improve outcomes.
Assists with preparation and presentation of utilization review monitoring/trending reports for review with physicians and hospital leadership.
Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
Instructs staff on best practices to ensure reimbursement based on medical care provided.
Maintains and reports clinical documentation improvement results in a clear and concise manner to the medical, clinical, and management staff.
Applies diplomacy and professionalism when interacting with physicians and clinical staff; especially when addressing missing or conflicting medical record information.