RN Utilization Review

UofL Health•Louisville, KY

1d•Onsite

About The Position

The Utilization Review RN performs activities supporting Utilization Management, including clinical recommendations regarding medical necessity for admission and continued stay, screening patients against client-specific insurance, Medicare, and Medicaid guidelines, and submitting 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 outcomes and appropriate use of facilities and services. The role conducts admission and concurrent reviews for observation and inpatient patients, identifies cases that may require a different level of care, and coordinates with the interdisciplinary health care team to support effective care and financial accountability. The RN applies the nursing and management processes to decision-making, maintains confidentiality, supports organizational objectives, and participates in ongoing UM competency validation and regulatory education. The role also serves as a resource to physicians and other staff on clinical management, financial matters, payer requirements, documentation, and compliance.

Requirements

Associate Degree in Nursing (ADN), or a Bachelor of Science in Nursing; a BSN is preferred.
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 the BSN within three years of employment.
Two years of experience as an RN.
Active Kentucky Registered Nurse license or compact license with privileges to work in Kentucky.
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 multiple 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 related to care management and utilization management.
Knowledge of service lines; sound nursing judgment; adherence to professional conduct and RN scope of practice.
Ability to adjust work hours based on departmental and organizational needs as determined by the director or manager of care coordination or the CNO.
Ability to communicate effectively verbally and in writing.
Critical thinking skills for complex patient situations, process improvements, and evidence-based practice; ability to assist others in developing clinical reasoning skills.
Proficient in Microsoft Word, Excel, and Outlook; basic computer and electronic medical record skills; ability to learn other relevant systems and databases.
For positions at Peace Hospital, three years of Behavioral Health experience is required.

Nice To Haves

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

Responsibilities

Conduct timely admission and concurrent utilization reviews for designated medical services, including observation and inpatient cases, and certify medical necessity for admission, continued stay, and discharge review using current MCG criteria.
Document clinical information, authorization numbers, and approved lengths of stay in the case management software system.
Review medical records for process delays affecting timely care and collaborate to ensure appropriate resources are used.
Determine appropriate admission status in accordance with regulatory and reimbursement requirements for commercial and government payers.
Communicate with third-party payers and provide pertinent clinical information to obtain authorizations.
Advocate for patient and family needs respectfully and confidentially.
Serve as a resource to physicians on clinical management and financial issues and help promote efficiency in care delivery.
Review cases for potential OIG Workplan audit and compliance issues; report problems and recommend actions to appropriate departments.
Refer unresolved cases involving lack of 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 resolve financial and billing problems, including patient status, payer source, denials, appeals, and system issues.
Develop cooperative relationships with third-party reviewers to facilitate timely responses for patient accounts.
Attend monthly departmental staff communications meetings and participate in committees and projects as needed.
Maintain professional growth through educational programs, current literature, in-service meetings, and workshops related to assigned responsibilities.
Comply with company policies, standards of conduct, HIPAA privacy and security requirements, and applicable safety standards.
Collaborate with team members and demonstrate effective customer service and professional conduct.
Perform other duties as assigned.