RN-Utilization Review (Remote Position - AZ Residents ONLY!)

Kingman Healthcare•Kingman, AZ

11d•Remote

About The Position

Kingman Healthcare Incorporated (KHI) is seeking a Utilization Review Nurse to join their Case Management department. This is a remote position open to AZ Residents ONLY. The Utilization Review Nurse is responsible for conducting and coordinating medical necessity reviews for all patients upon admission to inpatient or observation status and completing continued stay reviews throughout the stay. This role evaluates the surgical schedule for inpatient-only procedures (IPOs), verifies physician orders against Medicare and other payer guidelines, and ensures medical documentation accurately reflects the patient's severity of illness and acuity. The nurse will communicate with KHI medical staff to clarify orders and documentation for appropriate reimbursement, consult with the Physician Advisor for medical necessity determinations, and collaborate with Case Managers and Insurance Specialists to ensure timely and accurate clinical information is communicated to payers. The position also involves entering utilization review data into systems, maintaining documentation, collaborating with the healthcare team, business office, and payers, and participating in the denials management process. Additionally, the Utilization Review Nurse serves as a resource and educator for Case Management staff regarding clinical guidelines, utilization review, and payer regulations.

Requirements

Graduate from an accredited school of nursing
Minimum of three years clinical experience as an RN preferably in a hospital medical surgical or critical care setting.
Minimum one year of utilization review experience or two years case management experience as an RN
Current, valid Arizona or compact state RN license
Strong clinical skills and knowledge, and the ability to recognize when quality issues exist.
Knowledge of nationally recognized criteria used to make medical necessity determinations.
Strong interpersonal, organizational, and motivational skills, as well as proficiency in written and verbal communication.
Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open-minded, and adaptable to change.
Good assessment skills and knowledge of clinical and social factors that may affect the patient’s functional status at discharge.
Able to handle multiple priorities simultaneously.
Able to manage technical business equipment i.e., phone, fax, computer etc.
Ability to sit for 5-8 hours per day.
Ability to stand for 3-5 hours per day.
Ability to walk for 3-5 hours per day.

Nice To Haves

Experience using Milliman or InterQual criteria preferred.
BSN or MSN
CCM or ACM (will allow for time to obtain)

Responsibilities

Conducting and coordinating medical necessity reviews for all patients upon admission to inpatient or observation status and completing continued stay reviews throughout the stay.
Evaluating the surgical schedule for inpatient only procedures (IPOs) and communicating the need for appropriate orders.
Verifying physician orders in the medical record follow Medicare and other payer guidelines for determining level of care.
Assuring medical documentation accurately reflects the severity of illness and acuity of the patient.
Communicating with KHI medical staff as needed to reconcile and clarify admit orders and/or medical documentation to ensure that the hospital is reimbursed appropriately for services rendered.
Consulting with Physician Advisor as needed to make medical necessity determinations and/or make referrals for cases not meeting criteria as per KHI Utilization Management Plan.
Working collaboratively with Case Managers and Insurance Specialist to ensure that appropriate and accurate clinical information is communicated to payers within required timeframes as per KHI policies and procedures.
Responsible for complete, accurate and timely entry of information related to the utilization review process into data systems.
Maintaining documentation of all activities to support medical necessity determinations.
Collaborating with all members of the healthcare team, the business office, and payers as necessary, to ensure patients receive high quality care in the most cost-effective manner.
Collaborating with Denials Manager and RAC team to identify issues and/or trends related to medical necessity denials.
Participating in the denials management process.
Serving as a resource to Case Management staff and providing education and coaching regarding appropriate use of clinical guidelines, utilization review and payer regulations.
Establishing communications system for days off.
Assisting in sending admitting and discharge clinicals on all patients.
Reviewing Medical Records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria.
Evaluating medical information against nationally recognized criteria and determining necessity for admission, continued stay, appropriateness of service, and/or level of care.
Collaborating with the physicians to determine appropriate inpatient versus observation status and ensure appropriate documentation, and appropriate orders are entered.
Performing Code 44 when needed and communicating downgrades to appropriate staff.
Notifying Admitting, Insurance verifiers, and Apogee regarding status change of admission via email.
Determining which cases will require medical staff review intervention and/or UR management intervention.
Communicating with the attending physician, expected length of stay, Medicare guidelines and individual variances.
Collaborating with the Case Managers and Insurance Specialist to ensure appropriate documentation, awareness of potential denials, and any needs of clarification within the EMR from physician.
Assisting in educating Case Managers, Social Workers, and Physicians, changes in CMS guidelines, documentation requirements, etc.
Protecting patients’ rights as they pertain to the ethical and legal issues of confidentiality during the case management process.
Participating in committees, performance improvement activities, mandatory in-services, and continuing education.
Maintaining compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines.
Performing additional duties, as requested, such as: focused studies, appeal letters, outlier reporting, patient satisfaction initiatives, etc.