UTILIZATION REVIEW NURSE RN

HHC•Indianapolis, IN

1d•Onsite

About The Position

The Utilization Review Nurse works behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensures that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays. This position is responsible for ensuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standards.

Requirements

Current Indiana nursing license required
Minimum of 4 years clinical nursing experience required
Must demonstrate knowledge of the Utilization Management managed care processes
Competency in the following areas required: interpersonal, written/verbal communication, and negotiation skills diplomacy, flexibility, and professionalism cohesive networking with the Interdisciplinary Team

Responsibilities

Work behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensure that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays
Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process
Ensuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standards
Responsible for managing each patient's plan of care, monitoring for appropriate resource utilization, and collaborating with the inpatient team as well as outpatient providers to coordinate the patient's transition plan of care
Serves as a patient advocate, ensuring that efficient health care is provided. The role is to provide primary nurse support through all aspects of utilization management across the continuum of care and is not limited to the initial review process
Assesses degree of medical necessity for any patient seen in the Emergency Department and perform Utilization Review using the Eskenazi Health approved clinical decision support criteria
Reviews patients' admissions for appropriateness and type. Refers case to Medical Director and/or Department leadership for review when case fails to meet admission standards
Coordinates the most accurate and appropriate patient status for care
Identifies strategies to reduce the length of stay and resource consumption within the appropriate length of stay
Assesses patient's health status through collection of information from EMR, interview any other relevant sources to collect specific information in an attempt to provide the necessary determination for patient's status for appropriate medical regimen
Track readmissions and Emergency Department visits for patients assigned
Completes an admission review even when the patient under assessment has been relocated to an admitted or observation bed
Collaborates with Emergency Physicians and Attending Physicians to ensure that patients meet criteria for Admission, Placement on Observation Status or neither
Oversees the initial admission review, utilizing criteria, within 24-48 hours of the patient's admission to the hospital to ensure appropriateness of the assigned level of care and timely implementation of the treatment plan
Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation
Communicate with the Inpatient Case Manager to ensure appropriate status and level of care for patient, and that transition plan is implemented with determined goals in mind
Communicates with Payor Specialist for UR/UM to ensure proper status change and accurate billing practices
Evaluatesthe active funding for each patient and communicates with Inpatient Case Manager/Social Worker to facilitate initiation of appropriate funding applications
Demonstrates knowledge of levels of care of Inpatient and Outpatient status
Ensures that transitions to post-acute services such as Acute Rehabilitation Centers is appropriate and streamlined, and home care services, as well as durable medical equipment is appropriately utilized
Ensure the need for any services not provided at Eskenazi Health is evaluated and appropriate authorization is given and documented