Utilization Review Specialist Registered Nurse - Behavioral Health

Nurse

In conjunction with the admitting/attending physician, the UR Specialist RN assists in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews as directed in the hospital's UR Plan of medical records to ensure criteria for admission and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution.

Job Specific Duties and Responsibilities:

1. Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
2. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
3. Works collaboratively with case management to expedite patient discharge.
4. Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases.
5. Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.
6. Identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
7. Analyzes, updates, and modifies procedures and processes to continually improve utilization review operations.
8. Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
9. Complies with federal, state, and local legal and certification requirements by studying existing and new legislation; anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.
10. Performs other related duties as required and directed.

Required:

• Nursing degree from an accredited educational institution
• State of Michigan licensure as a Registered Nurse (RN)
• Two years of recent clinical or utilization management experience

Preferred:

• Bachelor's degree in nursing.
• Three years of recent case management or utilization management experience