Utilization RN - PRN

Utilization Review Nurse

This is a union position, PRN (as needed).

JOB SUMMARY

The Utilization Review Nurse reviews medical records and treatment plans to ensure patients receive appropriate, necessary, and cost-effective care while adhering to healthcare guidelines and policies. This position will be responsible for reviewing inpatient and outpatient authorizations. The Utilization RN will also serve as the care coordinator and discharge planner.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Coordinate and manage the safe and efficient discharge of patients from hospitals to their next phase of care.

Documenting patient care and staying up to date on the latest care recommendation guidelines.

Performing regular updates on patients' well-being.

Help develop treatment plans for patients.

Thoroughly examine patient records, including diagnoses, treatment plans, and procedures, to assess the appropriateness and necessity of care.

Evaluate the proposed or current treatment plans to determine if they align with established clinical guidelines, best practices, and patient needs.

Collaborate with healthcare providers, patients, and insurance companies to ensure seamless and coordinated care.

Identify and manage healthcare resources efficiently, ensuring that patients receive the necessary care without unnecessary or excessive services.

Maintain accurate and complete documentation of all reviews, decisions, and actions taken, ensuring compliance with relevant regulations and policies.

Review and process clinical appeals related to treatment denials or requests for services, providing justification for decisions based on medical necessity.

Advocate for patients by ensuring they receive the appropriate level of care and that their needs are met while managing healthcare costs effectively.

Communicate effectively with healthcare providers, patients, and other stakeholders to ensure clear understanding of treatment plans and decisions.

Audit charts on a daily basis to ensure we have the correct diagnosis and correct care to ensure we are able to bill appropriately.

Ensure that all inpatient admissions are properly documented and meet relevant criteria for admission.

Ensure that all outpatient services are properly documented and meet relevant criteria for testing.

Enters proper information into InterQual to assess the medical necessity of various healthcare services.

Perform related duties as assigned by management.

PROFESSIONAL REQUIREMENTS

Actively checks and responds to emails throughout the day.

Completes all mandatory education within the given timeframe.

Maintains regulatory requirements.

Reports to work on time and as scheduled.

Wears identification while on duty; uses computerized punch time system correctly.

Represents the organization in a positive and professional manner in the community.

Attends annual review and department in-services as scheduled.

Attends at least 75% of staff meetings; reviews all monthly staff meeting minutes.

Actively participates in the department's quality improvement (QI) activities.

Complies with all organizational policies regarding ethical business practices and the employee handbook.

Communicates the mission, vision and values of the organization as well as the focus of the department.

Meets dress code standards for the department; appearance is neat and clean.

All Ferry County Health employees are required to maintain confidentiality in accordance with organizational policy, state and federal regulations, including not but limited to, the Health Insurance Portability and Accountability Act (HIPAA).

JOB KNOWLEDGE & QUALIFICATIONS

Education and/or Work Experience Requirements

• Active Washington State Registered Nurse License Required.
• Previous nursing experience preferred in a similar position.
• Current BLS Certification.
• ACLS Certified within six (6) months of hire.
• TNCC within one (1) year of hire.
• PALS within one (1) year of hire.
• This is a safety sensitive position and subject to RCW 49.44.240(3)(g).

OTHER SKILLS & ABILITIES

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, patients, customers, and the general public.

Mathematical Skills

Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical solutions.

Reasoning Ability

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, and/or schedule form.

PHYSICAL AND / OR MENTAL DEMANDS

The attached Work Environment & Physical Demands addendum indicates the physical demands that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

STANDARDS OF BEHAVIOR

The Standards of Behavior were developed to reflect Ferry County Health's commitment to excellent community healthcare. The employee's commitment to practice these Standards of Behavior will promote an optimal environment of care and foster a positive work environment. Every employee is responsible for and must follow the Standards of Behavior.

Ferry County Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age (age 40 or older), sex (including pregnancy, gender identity, and sexual orientation), national origin, disability status, genetics, protected veteran status, or any other characteristic protected by federal, state or local laws.

THE ORGANIZATION

Ferry County Memorial Hospital (dba Ferry County Health) was established in Republic, Washington in 1945 and moved to its present facility in June of 1974. Until 1989, the Hospital was operated by the Ferry County Hospital Association, a private group composed of members of the community.

Ferry County Health is dedicated to improving health and saving lives in our community. Ferry County's Mission Statement is: To strengthen the health and well-being of our community through partnership and trust.

Benefits:

Medical, Dental, Vision paid 100% by Facility

3% Retirement match

Life Flight & Airlift NW Insurance

PTO

EIB

Employee Assistance Program

Local Discounts