RN Utilization Review, Peace Hospital

UofL Health•Louisville, KY

1d•Onsite

About The Position

The Utilization Review RN supports Utilization Management functions and is responsible for delivering the Utilization Management process. This includes making clinical recommendations about medical necessity for admissions and continued stays; screening patients against client-specific insurance, Medicare, and Medicaid guidelines; and sending payer-specific notices of admission and continued-stay reviews. The RN communicates payer approval or denial decisions to physicians and case managers, processes payer denials and retrospective reviews, and promotes optimal health care outcomes in accordance with UofL Health policies, procedures, applicable laws and contracts, philosophy, mission, and values. The role is accountable for appropriate use of facilities and services and serves as a resource to physicians. The RN conducts admission and concurrent reviews for observation and inpatient patients, identifies cases that do not meet criteria, and takes action to ensure patients receive care at the most appropriate level. In coordination with the interdisciplinary health care team, the RN facilitates optimal health outcomes and financial accountability. The role uses the nursing process and management process to guide decision-making, maintains confidentiality, and supports organizational goals by providing information to divisions and departments. UofL Health is a fully integrated regional academic health system with five hospitals, four medical centers, nearly 200 physician practice locations, more than 700 providers, the Frazier Rehab Institute, and Brown Cancer Center. With more than 12,000 team members, UofL Health’s mission is to deliver patient-centered care to every patient every day.

Requirements

Bachelor of Science in Nursing (BSN) required. An RN with a bachelor’s degree in Business, Health Care Administration, or equivalent may qualify on the condition of enrolling in a BSN program within one year of employment and completing the BSN within three years of employment.
Two years of experience as a registered nurse required.
Three years of behavioral health experience required for positions at Peace Hospital.
Active Kentucky Registered Nurse license or compact license with privileges to work in Kentucky.

Nice To Haves

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

Responsibilities

Conduct timely admission and concurrent utilization reviews for patients in designated medical services and certify medical necessity for admission, continued stay, and discharge reviews using current MCG criteria.
Document clinical information in the case management software system.
Evaluate medical records during concurrent reviews to identify process delays affecting timely care and collaborate to ensure appropriate resources are used.
Maintain processes for determining appropriate admission status in accordance with regulatory and reimbursement requirements of commercial and government payers.
Communicate with third-party payers to provide pertinent clinical information needed for authorization and document authorization numbers and approved lengths of stay in case management software.
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 remove barriers to effective services.
Review cases for potential OIG Workplan audit problems 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 manager or director of care coordination, CAO, or medical director, as appropriate.
Educate physicians, patients, and staff about payers, financial issues, documentation, and potential compliance issues.
Investigate and respond to billing concerns from the Business Office, Health Information Management, Admitting, and other sources; resolve financial and billing problems involving patient status, payer source, denials, appeals, and system issues.
Develop cooperative, supportive relationships with third-party reviewers to facilitate timely, positive responses for patient accounts.
Attend monthly departmental staff communications meetings and participate in committees and projects as needed.
Support professional growth through educational programs, current literature, in-service meetings, and workshops related to assigned responsibilities.
Comply with company policies, procedures, standards of conduct, and HIPAA privacy and security requirements.
Perform other duties as assigned.