RN Utilization Review

UofL Health•Louisville, KY

2d•Onsite

About The Position

The Utilization Review RN supports utilization management activities and performs reviews under established criteria, policies, and UM leadership oversight. The role evaluates medical necessity for admission and continued stay, reviews observation and inpatient cases against current MCG criteria and payer requirements, and communicates with physicians, case managers, and payors regarding authorization decisions. The RN documents clinical information and authorization details in case management software, processes denials and retrospective reviews, and helps ensure patients receive care at the most appropriate level. Working collaboratively with physicians and the interdisciplinary healthcare team, the RN identifies delays or barriers to care, promotes appropriate resource use, and supports optimal clinical outcomes and financial accountability. The position also serves as a resource on clinical management, payer and financial matters, documentation, and compliance; investigates billing concerns; and escalates cases when appropriate. The RN maintains confidentiality, complies with applicable laws, regulations, organizational policies, and professional standards, and participates in ongoing competency validation and regulatory education.

Requirements

Associate Degree in Nursing (ADN), or a bachelor's degree in nursing; a bachelor's degree in business, health care administration, or equivalent is accepted on the condition that the employee enrolls in a BSN program within one year of employment and completes it within three years.
Two years of experience as a registered nurse.
Active Kentucky Registered Nurse license or a compact license with privileges to work in Kentucky.
MCG Care Guidelines Specialist-ISC/GRC/Behavioral Health certification required within 12 months of hire.
Ability to adjust priorities quickly, organize multiple tasks, and work interdependently with staff at many levels.
Strong attention to detail, organizational, interpersonal, communication, and problem-solving skills.
Ability to maintain competency in care management and utilization management principles.
Knowledge of commercial and government payers and Joint Commission regulations, guidelines, and criteria related to utilization review.
Knowledge of state laws, CMS Conditions of Participation, and TJC standards related to care management and utilization management.
Knowledge of service lines; sound nursing judgment; and adherence to the professional code of conduct and RN scope of practice.
Ability to adjust work hours according to departmental and organizational needs as determined by leadership.
Ability to communicate effectively verbally and in writing.
Critical-thinking skills for complex patient situations, process improvement, and evidence-based practice.
Ability to assist others in developing clinical reasoning skills and to analyze problems, causes, and consequences.
Proficiency in Microsoft Word, Excel, and Outlook; basic computer skills, including electronic medical records; and ability to learn relevant systems and databases.
Ability to maintain confidentiality, protect sensitive data, collaborate with team members, and interact effectively with patients, providers, staff, and the broader healthcare community.

Nice To Haves

Bachelor of Science in Nursing (preferred).
One additional year of experience in case management or utilization management (preferred).
Case Management Certification (ACM, ANCC-Nurse Case Manager, or CCM) (preferred).

Responsibilities

Conduct timely admission and concurrent utilization reviews for assigned medical services, including observation and inpatient cases.
Evaluate and document medical necessity for admission, continued stay, and discharge reviews using current MCG criteria.
Review medical records to identify process delays and collaborate to ensure appropriate resources are used.
Support efficient admission-status determinations in accordance with regulatory and reimbursement requirements of commercial and government payers.
Communicate with third-party payors and provide pertinent clinical information to obtain authorizations; document authorization numbers and approved lengths of stay.
Communicate payer approval or denial decisions to physicians and case managers, and process denials and retrospective reviews.
Identify patients who do not meet criteria and take action to support care at the most appropriate level.
Coordinate with the interdisciplinary healthcare team to facilitate optimal health outcomes and financial accountability.
Advocate respectfully and confidentially for patient and family needs.
Serve as a resource to physicians on clinical management and financial issues, and help reduce barriers to efficient service delivery.
Review cases for potential OIG Workplan audit and compliance issues, report concerns, and make recommendations to appropriate departments.
Refer unresolved cases involving insufficient intensity of service or severity of illness to the appropriate manager, director, CAO, or medical director.
Educate physicians, patients, and staff about payers, financial issues, documentation, and potential compliance issues.
Investigate and respond to billing concerns and help resolve patient-status, payer-source, denial, appeal, and system issues.
Develop cooperative working relationships with third-party reviewers to facilitate timely responses for patient accounts.
Attend monthly departmental staff communications meetings and participate in committees or projects as needed.
Maintain professional knowledge and competency through education, current literature, in-service meetings, and workshops.
Comply with company policies, standards of conduct, HIPAA privacy and security requirements, and safety guidelines.
Collaborate with team members, demonstrate customer service, and perform other duties as assigned.