Utilization Review RN II, Care Coordination, Per Diem, Days

Utilization Review Nurse

About MarinHealth: Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare's most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch.

Company: Marin General Hospital dba MarinHealth Medical Center

Compensation Range: $66.03 - $99.04

Work Shift: 8 Hour (days) (United States of America)

Scheduled Weekly Hours: 0

Job Description Summary: The Utilization Review Nurse is responsible for completion of admission, concurrent and retrospective reviews for designated health plans. This function includes appropriate application of standardized criteria and concurrent documentation. As appropriate, the UR nurse will assess for clinical stability and coordinate transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals. The UR nurse is also responsible for initial RAC review prior to submission to Physician Advisor and will appeal medical necessity denials. Denials submitted to the case management department from Patient Financial Services will be reviewed to determine if the medical record has sufficient medical necessity documentation prior to a written appeal. The UR nurse will escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care.

Job Requirements, Prerequisites and Essential Functions:

Education:

• Bachelor of Science degree in Nursing preferred.

Experience:

• Three (3) or more years of experience in an acute patient care setting preferably in medical/surgical or critical care.
• Substantial recent experience in utilization review and/or discharge planning in an acute care setting is strongly preferred.
• Experience in applying evidence-based criteria related to utilization management.
• Experience using case management software

License and Certifications:

• California RN license (RN) required at hire
• Basic Life Support (BLS) required at hire

Prerequisite Skills:

• Must have the ability to read, write, and follow English verbal and written instructions, and have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills.
• Able to carry out review function and access medical records.
• Must have the ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities.
• Utilization review/discharge planning services appropriate to patients with complex
• Strong attention to detail and accuracy is required.
• Must have the ability to work in a high volume case load environment and deal effectively with rapidly changing priorities.
• Demonstrated ability to work constructively with a broad spectrum of health care professionals is required.
• Must be assertive and creative in problem solving, system planning and management.
• Proficient computer skills are required including use of Electronic Health Record. Microsoft Office Suite Products.

Primary Customer Served (Age Specific Criteria):

• Infants: Birth up to 1 year
• Toddlers: 1 up to 3 years
• Preschool Children: 3 up to 6 years
• School Age Children: 6 up to 12 years
• Adolescents: 12 up to 18 years
• Early Adults: 18 up to 45 years
• Middle Adults: 45 up to 61 years
• Late Adults: 61 up to 80 years
• Late, Late Adults: 80 years and up

Employees in this position must be able to demonstrate the knowledge and skills necessary to provide care and/or service based on the physical, psycho/social, educational, safety, and related criteria appropriate to the age of the patients served in his/her assigned service area.

Patient Privacy (HIPAA Compliance): Employees in this position have access to protected health information. The protected health information a person in this position can access includes demographics, date of service, insurance/billing, medical record summary information, and all other information that may be contained in patient records. This position requires patient health information to perform the functions outlined as part of this position description.

Duties And Responsibilities:

Essential (Not Modifiable)

Utilization Review

• Applies medical necessity criteria by completing an admission review upon hospital notification same day or within 24 hours.
• Documents the review within 24 hours of notification.
• Completes continued stay review and verifies treatment plan, that services ordered are appropriate, and determine if patient is stable for repatriation to Marin for designated health plans.
• Subsequent reviews are scheduled based on clinical findings and /or at the request of Medical Director.
• All reviews are conducted utilizing the approved criteria as defined by Marin General Utilization Management Plan.
• Issues a denial to the facility in the absence of medical necessity with approval of the Medical Director.
• Reviews discharge criteria and determine with treating facility if patient is ready for a safe discharge.
• Works with the treating facility to ensure the plan of care is expedited and barriers to efficient throughput are identified and corrected.
• Identifies the reported plan of care that outlines the key interventions and outcomes to be achieved each day of the inpatient stay.
• Identifies and refers quality and risk management concerns to appropriate level for corrective action plans and trending.
• The chain of command is utilized, or case is referred to Medical Director when appropriate and documented.

Denials and Appeal Management

• Reviews RAC medical necessity denials to determine if appeal is appropriate.
• Works with the Medical Director on complex RAC denials to determine if case will be appealed by third party reviewer.
• Submits an appeal letter following policy and procedure.
• Reviews non-RAC denials submitted by the Patient Financial Services and submit an appeal letter as appropriate.
• Recommends process or policy changes as necessary to avoid lost revenue as a result of denials/RAC requests/audits.
• Works directly with Medical Director to educate physicians on utilization and medical necessity.
• Follows timeline for appeal submission indicated by payors or regulatory agencies.
• Avoidable day entries are entered in MIDAS as indicated.
• Tracks response to appeals on a weekly basis and communicates with Patient Financial Services as needed for resolution of denied accounts. Reviews, processes, and issues denials to client/responsible party following regulatory guidelines and facility protocols.
• Collects data for the appeals process.
• Uses personal judgment within broad guidelines to initiate review of inappropriate utilization by physicians and follows-through to resolution (e.g., attending, department chair, utilization management medical director).

Department Operations and Development

• Actively participates in department meetings and operations, including process development or improvement (e.g., department orientation, internal mentor/training programs and initiates, disease and population management strategies, appropriate measures for evaluation of outcomes) and establishment of department goals, objectives, and budget.
• Ensures all applicable department and regulatory targets for productivity and department performance process improvement are attained (e.g., hospital length of stay, average cost per discharge, and re-admission rates, etc.).
• Complies with all reporting requirements for mandated, risk management, and other medical/legal situations consistent with confidentiality policies and department standards.
• Actively contributes to the development and maintenance of a care delivery system which is sensitive to individual patient needs, promotes effective resource utilization, and supports physician practice, while emphasizing coordination across the continuum.
• Positively contributes to team's decision-making process, effectively collaborates with other team members on interdependent tasks, and actively supports implementation of plans to accomplish team objectives.
• Prepares and conducts presentations to multidisciplinary teams related to special projects, case management, etc.