Utilization Review RN - FT - Day - Utilization Resource Mgmt Pennington NJ

Capital Health•Hopewell, NJ

21h•Onsite

About The Position

Capital Health is seeking a Utilization Review RN for its Utilization Resource Management department in Pennington, NJ. This role involves performing chart reviews to assess the quality, timeliness, and appropriateness of patient care. The RN will conduct admission reviews for various patient types based on established guidelines, screen for appropriateness of inpatient or observation levels of care, and refer cases to the UR physician advisor as needed. The position also includes gathering clinical information for continued stay reviews with payers, performing concurrent and retrospective reviews, and ensuring compliance with CMS guidelines. The RN will identify and implement strategies to reduce length of stay and resource consumption, provide coaching to physicians on level of care determinations, and stay current on regulatory changes affecting acute care services. Responsibilities also include advising physicians on national and local coverage determinations, understanding and applying federal law regarding HINN and Lifetime Reserve Days, identifying and recording avoidable days, and consulting with the medical staff and care team to resolve progression of care barriers. The role involves collaborative problem-solving with care team colleagues, responding to patient safety and risk factors, representing Utilization Management at committees, and promoting evidence-based protocols for high-quality, cost-effective care. The RN will also promote medical documentation that accurately reflects patient status and need for continued stay, identify preventable delays, maintain documentation in the Utilization software system, and participate in daily huddles and patient care conferences. Analysis of clinical protocols to identify and recommend alternatives for wasteful or misused resources is also a key function. The position requires maintaining related continuing education credits.

Requirements

Minimum of Associate's degree in Nursing.
Graduate of an accredited school of nursing.
Three years of clinical nursing or two years quality management, utilization review or discharge planning experience.
Registered Nurse - NJ
Three years of clinical nursing or two years quality management, utilization review or discharge planning experience.
Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR.
Possesses familiarity with MCG guidelines.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Nice To Haves

CPHQ, CCM or CPUR preferred.

Responsibilities

Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care.
Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines.
Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay).
Refers cases as appropriate, to the UR physician advisor for review and determination.
Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis.
Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines.
Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee.
Identifies, develops and implements strategies to reduce length of stay and resource consumption.
Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry.
Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services.
Uses knowledge of national and local coverage determinations to appropriately advise physicians.
Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters.
Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program.
Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels.
Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources.
Recognizes and responds appropriately to patient safety and risk factors.
Represents Utilization Management at various committees, professional organizations an physician groups as needed.
Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care.
Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population.
Participates in performance improvement activities.
Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay.
Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes.
Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities.
Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care.
Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols.
Maintains related continuing education credits = 15 per calendar year.