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 Basic Life Support Health Care Provider card. Proficiency in application of InterQual Criteria, knowledge of ICD-9, DRG's and CPT Codes. Utilization Review Certification designation. Knowledge of CMS Regulations. Working Conditions and Physical Demands 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 Sitting Multi-lingual Candidates Welcomed EEO Statement University of Utah Health Hospitals and Clinics, a part of The University of Utah, values candidates who have experience working in settings with students and patients from all backgrounds and possess a strong commitment to improving access to higher education and quality healthcare for historically underrepresented students and patient populations. All qualified individuals are encouraged to apply. Veterans’ preference is extended to qualified applicants, upon request and consistent with University policy and Utah state law. Upon request, reasonable accommodations in the application process will be provided to individuals with disabilities. University of Utah Health Hospitals and Clinics, a part of The University of Utah, is an Affluent Action/Equal Opportunity employer and does not discriminate based upon race, ethnicity, color, religion, national origin, age, disability, sex, sexual orientation, gender, gender identity, gender expression, pregnancy, pregnancy-related conditions, genetic information, or protected veteran's status. The University does not discriminate on the basis of sex in the education program or activity that it operates, as required by Title IX and 34 CFR part 106. The requirement not to discriminate in education programs or activities extends to admission and employment. Inquiries about the application of Title IX and its regulations may be referred to the Title IX Coordinator, to the Department of Education, Office for Civil Rights, or both. To request a reasonable accommodation for a disability, please contact the University of Utah Health Hospitals and Clinics Human Resources office at View phone number on click.appcast.io. If you or someone you know has experienced discrimination or sexual misconduct including sexual harassment, you may contact the Director/Title IX Coordinator in the Office of Equal Opportunity (OEO). More information, including the Director/Title IX Coordinator's office address, electronic mail address, and telephone number can be located at: Online reports may be submitted at oeo.utah.edu/ University is a participating employer with Utah Retirement Systems ("URS"). Eligible new hires with prior URS service, may elect to enroll in URS if they make the election before they become eligible for retirement (usually the first day of work). Contact Hospitals and Clinics Human Resources at View phone number on click.appcast.io for information. Individuals who previously retired and are receiving monthly retirement benefits from URS are subject to URS’ post-retirement rules and restrictions. Please contact Utah Retirement Systems at View phone number on click.appcast.io or View phone number on click.appcast.io or Hospitals and Clinics Human Resources at View phone number on click.appcast.io if you have questions regarding the post-retirement rules. #J-18808-Ljbffr Utah