RN Utilization Review Weekend Nights
About The Position
The Utilization Review RN performs admission and continued stay utilization reviews and discharge screening to assure the medical necessity of hospital admission, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services. Collaborates with attending physicians, advanced practice providers, and/or Department Medical Directors concerning status and/or medical necessity issues. Follows departmental policy to escalate cases to second level review when criteria is in question. The UR RN consistently interacts with physicians, nurses, revenue cycle services, other patient caregivers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patient and the clinical information utilized in profiling and reporting outcomes is completed. Monitors and evaluates care to ensure care is medically necessary, provided in the appropriate setting, and generated according to governmental and regulatory agency standards. Talent Pool: Nursing Conducts initial case reviews within 24 hours of admission and continues reviews as long as the patient is hospitalized, following all relevant regulations. Reviews are documented in EPIC, and clinical information is securely transmitted to carriers, with outcomes communicated to relevant medical and hospital staff. Refers appropriate cases to the Physician Advisor promptly and communicates effectively with peers to ensure patient needs are met. Acts as a liaison between physician and payor regarding non-coverage of benefits or denials. Oversees resource utilization, identifies and addresses issues promptly with the healthcare team, and educates them on payer requirements, denials, and regulatory compliance. Monitors patient status authorizations, documents code 44 processes, and documents avoidable days before discharge. Documents UR processes and supports the healthcare team by providing comprehensive documentation in the EMR/Epic. Maintains clinical/authorization documentation to minimize denials and coordinates with the denials team on appeals. Monitors readmissions, reporting trends and possibilities to the transition of care nurse. Performs other duties as assigned.
Requirements
- Bachelor?s Degree in Nursing or healthcare-related field
- 3 years as a Registered Nurse
- Registered Nurse license in North Carolina or a Compact state
Responsibilities
- Performs admission and continued stay utilization reviews and discharge screening
- Collaborates with physicians and other healthcare providers
- Escalates cases to second level review when criteria is in question
- Interacts with physicians, nurses, revenue cycle services, other patient caregivers, and coding professionals
- Monitors and evaluates care to ensure medical necessity and appropriate setting
- Conducts initial case reviews within 24 hours of admission and continues reviews as long as the patient is hospitalized
- Documents reviews in EPIC and transmits clinical information securely
- Refers cases to the Physician Advisor and communicates with peers
- Acts as a liaison between physician and payor
- Oversees resource utilization and educates the healthcare team
- Monitors patient status authorizations and documents code 44 processes
- Documents UR processes and supports the healthcare team in the EMR/Epic
- Maintains clinical/authorization documentation to minimize denials
- Monitors readmissions and reports trends to the transition of care nurse
- Performs other duties as assigned
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What This Job Offers
Career Level
Mid Level
Industry
Religious, Grantmaking, Civic, Professional, and Similar Organizations
Number of Employees
5,001-10,000 employees
