Registered Nurse-Utilization Review

Registered Nurse-Utilization Review

One of our direct client is looking for Registered Nurse-Utilization Review details are as follows:

The below are the notes directly for the hiring manager. The nurse will be receiving and processing clinical information on patients that are in the hospital. So if they haven't worked in the past doing utilization review, then they need to have current or recent experience in working in the hospital, preferable in a specialty unit like Emergency room or intensive care units. We get a variety of adults and pediatric members with various medical conditions and will process the information and determine necessity of the hospital days using standardized criteria. The information comes over on a fax from the nurse in the hospital, and we type or cut and paste the information into the members inpatient case. We interact with a physician if necessary. Employee would need to be computer savvy and can know how to type and be comfortable using different computer systems. It is a fast pace job and requires quick thinking and prompt processing of many reviews within a day.

Job Summary: This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management.

Responsibilities:

• Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
• Coordinates and assists in implementation of plan for members.
• Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate.
• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
• Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
• Encourages member participation and compliance in the case/disease management program efforts.
• Documents accurately and comprehensively based on the standards of practice and current organization policies.
• Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
• Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
• Completes other assigned functions as requested by management.

Core Individual Contributor Competencies. Personal and professional attributes that are critical to successful performance for Individual Contributors: Customer Focus, Accountable, Learn, Communicate. Qualifications: Education/Experience 1. Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. 2. Requires a minimum of two (2) years clinical experience. Additional licensing, certifications, registrations: 1. Requires an active New Jersey Registered Nurse License.

Knowledge: - Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications. - Prefers working knowledge of case/care management principles. - Prefers working knowledge of principles of utilization management. - Prefers basic knowledge of health care contracts and benefit eligibility requirements. - Prefers knowledge of hospital structures and payment systems. Skills and Abilities: - Analytical - Compassion - Interpersonal & Client Relationship Skills - Judgment - Listening - Planning/Priority Setting - Problem Solving - Team Player - Time Management - Written/Oral Communication & Organizational Skills

TECHNICAL KNOWLEDGE:

• Able to work well in cross-functional teams, exhibiting a combination of active listening skills and also the confidence to guide decision-making for the document content strategy.

• Able to manage expectations and the time pressures associated with authoring, resolving comments, updating and finalizing documents.

• Able to complete and turn around high quality outputs with only minimal guidance from management.