RN Utilization Review, Frazier Rehab Institute

UofL Health•Louisville, KY

6d•Onsite

About The Position

The RN Utilization Review performs activities supporting the Utilization Management process. The role makes clinical recommendations regarding medical necessity for admission and continued stay; screens patients against payer-specific, Medicare, and Medicaid guidelines; and sends payer-specific notices of admission and continued-stay reviews. Under established criteria, policies, and UM leadership oversight, the RN communicates payer approvals and denials to physicians and case managers, processes denials and retrospective reviews, and promotes optimal care outcomes and appropriate use of facilities and services. The RN conducts admission and concurrent reviews, including observation and inpatient cases, identifies patients who may not meet criteria, and works to ensure care is provided at the appropriate level. The position coordinates with the interdisciplinary healthcare team, applies nursing and management processes to decision-making, maintains confidentiality, and participates in ongoing competency validation and regulatory education. The RN conducts timely utilization reviews, certifies medical necessity using current MCG criteria, documents clinical information and authorization details in case management software, and collaborates to address delays affecting timely patient care. The role communicates with third-party payors, advocates for patient and family needs, serves as a resource to physicians on clinical management and financial issues, reviews cases for audit and compliance concerns, and refers unresolved cases to appropriate leadership. The RN also educates physicians, patients, and staff on payer, financial, documentation, and compliance matters; investigates billing concerns; and helps resolve patient-status, payer-source, denial, appeal, and system issues. The position supports cooperative relationships with third-party reviewers, attends departmental communications meetings, may serve on committees, and pursues ongoing professional development. It requires compliance with organizational policies, HIPAA privacy and security requirements, and applicable regulatory and payer standards. Work hours may need to be adjusted according to departmental and organizational needs, as determined by the director or manager of care coordination or the CNO.

Requirements

Active Kentucky Registered Nurse license or compact license with privileges to work in Kentucky.
Two years of experience as a registered nurse.
ADN or qualifying bachelor's degree; an RN with a bachelor's degree in business, health care administration, or equivalent must enroll in a BSN program within one year of employment and complete it within three years of employment.
Obtain MCG Care Guidelines Specialist-ISC/GRC/Behavioral Health certification within 12 months of hire.
Ability to adjust priorities quickly, organize multiple tasks simultaneously, and work interdependently with staff at different levels.
Strong attention to detail, organizational, interpersonal, and communication skills, and innovative problem-solving skills.
Ability to maintain competency in care management and utilization management principles and current 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 applicable to care management and utilization management.
Knowledge of service lines; sound nursing judgment; adherence to professional conduct and RN scope of practice.
Ability to communicate effectively verbally and in writing.
Ability to critically think through complex patient situations, process improvements, and evidence-based practice; help others develop clinical reasoning; and analyze causes and consequences of events.
Proficiency in Microsoft Word, Excel, and Outlook; basic computer skills, including use of electronic medical records; and capacity to learn relevant systems and databases.
Ability to adjust work hours according to departmental and organizational needs, as determined by the director or manager of care coordination or the CNO.
Commitment to service, organizational values, professionalism, confidentiality, safety standards, teamwork, and customer service.

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).
Three years of behavioral health experience is required for positions at Peace Hospital.

Responsibilities

Conduct timely admission and concurrent utilization reviews for patients in designated medical services.
Certify medical necessity for admission, continued stay, and discharge reviews using current MCG criteria, and document clinical information in the case management software system.
Evaluate medical records during concurrent reviews to identify process delays affecting timely patient care and collaborate to ensure appropriate resources are used.
Maintain efficient processes for determining appropriate admission status in accordance with regulatory and payer reimbursement requirements.
Communicate with third-party payors, provide pertinent clinical information to obtain authorization, and document authorization numbers and approved lengths of stay.
Advocate for patient and family needs respectfully, non-judgmentally, and confidentially.
Serve as a physician resource on clinical management and financial issues, and help promote efficient care delivery and reduce barriers to effective service.
Review cases for potential OIG Workplan audit and compliance issues, report problems, and recommend actions to appropriate departments.
Refer cases to care coordination leadership, the CAO, or the medical director when severity of illness or intensity of service is not present and the issue cannot be resolved.
Educate physicians, patients, and staff about payors, financial issues, documentation, and potential compliance issues.
Investigate and respond to billing concerns from the Business Office, Health Information Management, Admitting, and other sources; 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 as needed.
Participate in educational programs and other professional development activities related to assigned responsibilities.
Maintain compliance with company policies, procedures, standards of conduct, HIPAA privacy and security requirements, and applicable safety standards.
Collaborate with team members and demonstrate professional, effective customer service to physicians, patients, residents, visitors, staff, and the broader healthcare community.
Perform other duties as assigned.