Utilization Review Nurse (RN)

Job Purpose Responsible for utilization of clinical and financial resources by ensuring appropriate clinical level of care, performing and submitting clinical information to external payers to secure proper authorization, collaborating with the Care Coordinator to develop and implement the plan of care, serving as a primary resource to the Utilization Review Nurse I (LPN), and ensuring prompt notification of any denials to the appropriate Care Coordinator, Denials/Appeals Coordinator, and Team Leader. Performs all job duties for the age population served, as defined in the department's scope of service. Performance Criteria CRITERIA A: Everyday Excellence Values Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community. Takes initiative in living our Everyday Excellence values. Identifies customer needs proactively. Participates in teamwork with willingness and enthusiasm. Respects the dignity and privacy of customers through personal action and attention to the environment of care. Keeps customers informed, answers questions, and anticipates information needs. CRITERIA B: Corporate Compliance Practices diligence in fulfilling regulatory and legal requirements. Maintains accurate and reliable patient/organizational records. Communicates honestly and behaves fairly and nondiscriminately in all professional contacts. CRITERIA C: Personal Achievement Uses accepted procedures and practices to complete assignments. Employs creative and proactive solutions to achieve objectives under high workload and demands. Adheres to high moral principles of honesty, loyalty, sincerity, and fairness. Upholds ethical standards of the organization. CRITERIA D: Performance Improvement Optimizes talents, skills, and abilities to exceed customer expectations. Initiates or redesigns processes to continuously improve work. Contributes ideas and suggestions to improve approaches to work processes. Participates willingly in organizational or departmental quality initiatives. CRITERIA E: Cost Management Effectively manages time and resources. Utilizes organizational resources—material, human, and financial—consciously. Consistently seeks and uses resource‑saving processes. CRITERIA F: Patient & Employee Safety Effectively communicates, demonstrates, coordinates, and emphasizes patient and employee safety. Proactively reports errors, potential errors, injuries, or potential injuries. Demonstrates departmental specific patient and employee safety standards at all times. Uses proper safety techniques, equipment, and devices and follows safety policies, procedures, and plans. Essential Job Functions 1. Coordinate utilization of clinical and financial resources Identifies accurate payer information for each assigned patient. Communicates and collaborates with admission/precertification department to ensure appropriate payer precertification. Performs admission review on all assigned inpatients and observations within one business day of admission for appropriateness based on medical necessity and InterQual criteria. Refers appropriate cases to physician advisor or designee. Communicates with admitting physicians to ensure correct admission level of care. Performs concurrent review on all assigned patients for appropriateness of level of care and continued stay based on medical necessity using InterQual criteria. Contacts physicians and/or Care Coordinators for additional information on cases not meeting medical necessity criteria. Identifies and refers problem cases to appropriate Care Coordinators or supervisors. Maximizes reimbursement by communicating pertinent clinical information to payers. Ensures physician documentation supports current clinical level of care. Collaborates with Intake Nurse/ Care Coordinator to assist with appropriate interventions to avoid denial of payment. Assists in arranging peer‑to‑peer conferences to avoid denial of payment. Assists in denials/appeals processes. Identifies opportunities for more efficient resource utilization. Serves as a primary resource to the Utilization Review Nurse I (LPN), including assisting with cases not meeting medical necessity criteria and communicating with external payers. Ensures appropriate orders are written by physicians when level of care is changed. Assists with cases that have been issued denials and/or rejections. Collaborates with the Care Coordinator in developing and implementing the plan of care. Documents patient information in Provider Link regarding level of care, authorizations, and approved/denied days. Communicates with payers regarding discharges by sending notifications as appropriate. Closes out each case once authorization is complete. Coordinates with insurance specialists to ensure timely and complete authorizations. 2. Participate in quality improvement activities Reports sentinel events and quality of care issues to the Director of Case Management. Collects and tracks data (denials, avoidable days, etc.) as determined by Supervisor or Director. Participates in performance improvement activities as needed. 3. Perform all other duties as assigned. Requirements Experience Requirements Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and local and national coverage determinations. Recent work experience in the hospital or insurance industry. Educational Requirements Current Louisiana RN licensure. Special Skills, Licenses, and Knowledge Requirements Knowledge of human behavior, socioeconomic factors in disease, and behavior patterns of physically and mentally ill patients. Outstanding communication skills to establish constructive relationships with patients, families, payers, and hospital associates. Advanced knowledge of regulatory and payer requirements related to level of care, medical documentation, and medical necessity. Ability to work well under time pressure and shifting priorities. ACM or CCM certification preferred. HIPAA Requirements Maintains knowledge of and adherence to all applicable HIPAA regulations, including medical records (paper and electronic), patient demographics, lab and radiology results, surgery or appointment schedules, patient location, religious beliefs, public health records, quality data, financial information, 3rd‑party billing, complaints, research information, employee health records, and prescriptions. Safety Requirements Maintains knowledge of and adherence to all applicable safety practices, including incident reporting, PPE, exposure control plans, hand washing, environment of care, and patient identification. #J-18808-Ljbffr Baton Rouge General Medical Center