Utilization Review Nurse

Overview

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA

This position is responsible for maintaining the financial integrity of both the patient and the organization through the provision of quality based patient care focusing on the medical necessity and efficiency of the delivery of such care; achieved via managing the cost of care while providing timely and accurate information to third party payers and medical care team. This position may be required to access and administer medications within their scope of practice and according to state law.

Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

Responsibilities

Essential Functions

• Applies approved utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review.
• Communication to third-party payers for initial and concurrent clinical review.
• Reviews patient chart to ensure patient continues to meet medical necessity.
• Documentation of all actions and information shared with care team members or third-party payer.
• Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay.
• Discusses with physicians the appropriateness of resource utilization.
• Tracks length of stay (LOS) and resource utilization to identify at risk patients.
• Refers to UR committee any case that surpasses expected LOS, expected cost, or over/under-utilization of resources.
• Performs verbal/fax clinical review with payer as determined by nursing judgment and/or collaboration with the payer per university contractual obligation.
• Participant in UR Committee as needed.
• Collects data on variances in LOS, avoidable days, costs/barriers to discharge/transition and denied days.
• Prepares appeals on denied cases when appropriate.
• At the discretion of department operational and patient care needs, this position is required to work rotating schedules, which may include variable hours, weekends, nights, and holidays to meet the staffing and patient care demands of a 24/7 complex health system. Regular, reliable, and punctual attendance during assigned shifts is considered an essential function of the role.

Knowledge / Skills / Abilities

• Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment.

• Ability to perform the essential functions of the job as outlined above.

• Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills.

• Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria.

• The ability to demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.

• Ability to work autonomously and as a team member.

Qualifications

Required

• One year Utilization Review or Case Management experience.

Licenses Required

• Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah. Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah.

* Additional license requirements as determined by the hiring department.

Qualifications (Preferred)

Preferred

• Knowledge of ICD-10, CPT Codes, and medications HCPCS
• Knowledge of CMS Regulations.

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions. This position does not provide care to patients.

Physical Requirements

Carrying, Color Determination, Crawling, Far Vision, Lifting, Listening, Manual Dexterity, Near Vision, Pulling and/or Pushing, Reaching, Sitting, Speaking, Standing, Stooping and Crouching, Walking