RN Utilization Review, Peace Hospital

UofL Health•Louisville, KY

2d•Onsite

About The Position

The Utilization Review RN supports Utilization Management functions and delivers the Utilization Management process. The role makes clinical recommendations regarding medical necessity for admission and continued stay, screens patients against client-specific insurance, Medicare, and Medicaid guidelines, and sends payer-specific notices of admission and continued-stay reviews. The RN communicates with physicians and case managers about payer approvals and denials, processes 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 RN is accountable for appropriate use of facilities and services and serves as a resource to physicians. The position conducts admission and concurrent reviews for observation and inpatient patients, identifies patients who do not meet criteria, and takes action to ensure care is delivered at the most appropriate level. The RN coordinates with the interdisciplinary healthcare team to support optimal health and financial accountability, uses nursing and management processes to guide decision-making, maintains confidentiality, and supports organizational goals by providing information to divisions and departments. The position is based at Peace Hospital in Louisville, Kentucky, and is listed as a first-shift role.

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 that they enroll in a BSN program within one year of employment and complete it within three years of employment.
Two years of experience as an RN 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, 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 review to identify process delays affecting timely patient care and collaborate to ensure appropriate resources are used.
Maintain effective processes for determining appropriate admission status based on 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 the case management software.
Advocate respectfully, non-judgmentally, and confidentially for patient and family needs.
Serve as a resource to physicians on clinical management and financial issues, and help providers improve care delivery efficiencies and reduce barriers to effective service.
Review cases for potential OIG Workplan audit and compliance issues, report problems, and make recommendations to appropriate departments.
Refer cases to the manager/director of care coordination, CAO, or medical director when intensity of service or severity of illness is not present and the issue cannot be resolved.
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 working 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.