RN - Utilization Review; Senior Care
About The Position
The Behavioral Health Utilization Review (UR) Nurse ensures appropriate utilization of inpatient psychiatric services for geriatric patients through medical necessity review, level-of-care validation, documentation compliance, and denial prevention activities. This role supports compliance with: 42 CFR §482.30 (Utilization Review); 42 CFS §482.60 (Psychiatric Services Conditions of Participation); Medicare Inpatient Psychiatric Facility (IPF); Prospective Payment System; Arkansas Nurse Practice Act The UR Nurse applies approved behavioral health criteria to ensure medical necessity, appropriate length of stay, and regulatory compliance in the acute geriatric behavioral health setting. Scope of Role by Licensure: Perform independent clinical review and determination using approved criteria. Recommend level-of-care adjustments. Conduct peer discussions with providers. Participate in denial peer-to-peer preparation. Serve as clinical liaison to Physician Advisor. Demonstrates Competency in the Following Areas: Reviews psychiatric admissions for: Acute behavioral instability; risk of harm to self or others; severe mood disturbance; psychosis; medication stabilization needs; and dementia with behavioral disturbance requiring inpatient care. Validates documentation of: psychiatric evaluation within required timeframe; admission certification; individualized treatment plan; and active treatment documentation. Conducts ongoing review to confirm: continued acute psychiatric criteria; active treatment progression; medication adjustments and response; and multidisciplinary plan updates. Monitors length of stay (LOS) against benchmarks. Identifies avoidable days and discharge barriers (placement, guardianship, SNF acceptance). Ensures documentation reflects acuity beyond custodial care in cases involving: major neurocognitive disorder with behavioral disturbance; delirium vs psychiatric decompensation; late-life depression; bipolar disorder; psychosis; polypharmacy complications and behavioral symptoms requiring structured milieu and medication adjustment. Identifies documentation gaps impacting severity-of-illness and intensity-of-service. Collaborates with providers to strengthen documentation. Assists with appeal preparation. Tracks denial trends specific to psychiatric services. Ensures compliance with: Active treatment requirements; 7-day treatment plan reviews; recertification requirements; seclusion and restraint documentation standards; and IPF PPS documentation standards. Participates in UR Committee and Behavioral Health QAPI processes. Tracks and reports: Average Length of Stay (ALOS); denial rate; avoidable patient days; 30-day readmissions; transfer-out rates; and certification compliance rate. Prepare utilization reports for: Behavioral Health Program Director; Executive Administration team; and Governing Board.
Requirements
- Current RN Licensure in the state of Arkansas.
- Minimum 3 years' experience in Acute psychiatric nursing and geriatric behavioral health.
- Experience in case management or utilization review preferred.
- Ability to effectively communicate in English, both verbally and in writing.
- Strong written and verbal skills.
- Strong understanding of acute psychiatric documentation standards.
- Knowledge of geriatric psychiatric presentations.
- Ability to analyze medical necessity.
- Strong communication skills with physicians and interdisciplinary team.
- Ability to escalate appropriately within scope.
- Proficiency with electronic health records and reporting systems.
Nice To Haves
- Experience with InterQual or MCG Behavioral Health criteria.
- Knowledge of Medicare IPF PPS reimbursement.
- Behavioral Health or Case Management certification.
- Experience with denial management.
- Additional languages preferred.
Responsibilities
- Reviews psychiatric admissions for: Acute behavioral instability; risk of harm to self or others; severe mood disturbance; psychosis; medication stabilization needs; and dementia with behavioral disturbance requiring inpatient care.
- Validates documentation of: psychiatric evaluation within required timeframe; admission certification; individualized treatment plan; and active treatment documentation.
- Conducts ongoing review to confirm: continued acute psychiatric criteria; active treatment progression; medication adjustments and response; and multidisciplinary plan updates.
- Monitors length of stay (LOS) against benchmarks.
- Identifies avoidable days and discharge barriers (placement, guardianship, SNF acceptance).
- Ensures documentation reflects acuity beyond custodial care in cases involving: major neurocognitive disorder with behavioral disturbance; delirium vs psychiatric decompensation; late-life depression; bipolar disorder; psychosis; polypharmacy complications and behavioral symptoms requiring structured milieu and medication adjustment.
- Identifies documentation gaps impacting severity-of-illness and intensity-of-service.
- Collaborates with providers to strengthen documentation.
- Assists with appeal preparation.
- Tracks denial trends specific to psychiatric services.
- Ensures compliance with: Active treatment requirements; 7-day treatment plan reviews; recertification requirements; seclusion and restraint documentation standards; and IPF PPS documentation standards.
- Participates in UR Committee and Behavioral Health QAPI processes.
- Tracks and reports: Average Length of Stay (ALOS); denial rate; avoidable patient days; 30-day readmissions; transfer-out rates; and certification compliance rate.
- Prepare utilization reports for: Behavioral Health Program Director; Executive Administration team; and Governing Board.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
