Utilization Review Nurse - Medication Access

University of Utah Health•Murray, UT

55d•Onsite

About The Position

This position is responsible for maintaining the financial integrity of both the patient and the organization through the provision of quality based patient care focusing on the medical necessity and efficiency of the delivery of such care; achieved via managing the cost of care while providing timely and accurate information to third party payers and medical care team. This position may be required to access and administer medications within their scope of practice and according to state law. The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

Requirements

One year Utilization Review or Case Management experience.
Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah. Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah.
Additional license requirements as determined by the hiring department.
Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment.
Ability to perform the essential functions of the job as outlined above.
Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills.
Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria.
The ability to demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.
Ability to work autonomously and as a team member.

Nice To Haves

Knowledge of ICD-10, CPT Codes, and medications HCPCS
Knowledge of CMS Regulations.

Responsibilities

Applies approved utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review.
Communication to third-party payers for initial and concurrent clinical review.
Reviews patient chart to ensure patient continues to meet medical necessity.
Documentation of all actions and information shared with care team members or third-party payer.
Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay.
Discusses with physicians the appropriateness of resource utilization.
Tracks length of stay (LOS) and resource utilization to identify at risk patients.
Refers to UR committee any case that surpasses expected LOS, expected cost, or over/under-utilization of resources.
Performs verbal/fax clinical review with payer as determined by nursing judgment and/or collaboration with the payer per university contractual obligation.
Participant in UR Committee as needed.
Collects data on variances in LOS, avoidable days, costs/barriers to discharge/transition and denied days.
Prepares appeals on denied cases when appropriate.
At the discretion of department operational and patient care needs, this position is required to work rotating schedules, which may include variable hours, weekends, nights, and holidays to meet the staffing and patient care demands of a 24/7 complex health system. Regular, reliable, and punctual attendance during assigned shifts is considered an essential function of the role.