RN Utilization Review Specialist

Job Summary Comprehensively plans with the health care team to ensure patient needs are met and care delivery is coordinated across the continuum. Identifies and works to eliminate/minimize system variation and service delivery barriers that prevent achievement of optimal patient outcomes in the expected time frame and with the most efficient utilization of resources. Carries out activities related to utilization management, discharge planning, care coordination and referral to other levels of care. Performs as an integral part of the interdisciplinary team promoting interdisciplinary collaboration. Facilitates assignment of level of care, considers payer requirements and responds accordingly to avoid adverse financial consequence to patient and hospital. Provides superior customer service by modeling the We Care Standards. Essential Functions Learns all aspects of the position, including revised methods, within appropriate time frames. Attends in‑services and educational programs provided by the Hospital and applies the information received. Identifies self‑development needs and uses available educational resources. Identifies and supports the delivery of positive customer service to all customers (patients, visitors, families, physicians, staff, etc.). Conducts all interactions in a confidential and courteous, professional and timely manner. Recognizes and responds appropriately to the needs of all customers. Conducts accurate assessments of patients. Determines appropriateness of admission, continued stay, potential for discharge planning interventions and level of care based on approval criteria and standards. Communicates with physician regarding appropriate documentation for justification. Reviews the patient’s plan of care in conjunction with the clinical pathway, individualizing clinical outcomes, and reviewing same with patient/family. Utilizes Clinical Pathways to coordinate resources and services to ensure continuity of care and optimum use of hospital resources; determines variances from pathway and refer to appropriate advisor. Monitors the appropriateness and quality of patient care; refers identified quality issues to the Performance Improvement Dept.; participates in concurrent Quality audits as directed. Maintains working knowledge of payer source requirements and government regulations, current knowledge of JCAHO, NYSDOH, IPRO, as well as knowledge of available community and health care resources. Acts as patient advocate, negotiating for needed services with third party payers, resolving patient complaints and/or redirecting to appropriate sources, and makes appropriate referrals within one working day. Participates in Performance Improvement activities in the Case Management Department, making recommendations to improve hospital‑wide system. Participates in interdisciplinary rounds and develops a physician‑directed plan of care for post‑hospital services in collaboration with the health care team, patient/family. Initiates home‑care referrals for provision of services, and arranges for supplies and equipment required by the patient. Plans transfers to nursing facilities, rehab and other acute care facilities and provides accurate information through completion of H/C PRI/Screen, HC 485, Level 11, etc. Involves patient/family in the decision‑making process regarding the selection of post‑hospital care, and informs them concerning insurance coverage, co‑payments and Medicare/Medicaid guidelines. May take orders from physicians including but not limited to discharge orders. Conducts clinical reviews utilizing objective criteria (Interqual) to assign patient to the appropriate level of care; identifies clinical resources required to achieve optimal patient outcomes and appropriate reimbursement for the hospital. Documents level of care and medical necessity in the Care Management database to support the clinical review process. Concurrentlly monitors resource utilization, performing continued stay reviews and assists with managing length of stay of patients. Concurrentlly communicates clinical information to payors; severity of illness, intensity of service and plan of care. Performs retrospective reviews on insurance denials and assists in appeal process. Qualifications Bachelor Degree (Preferred) or Associate Degree (Required) 4–6 years relevant clinical medical surgical, ICU or ER experience (Preferred) Preferred Membership in a professional organization (Preferred) Effective written and verbal communication skills, decision‑making and problem‑solving skills, and comprehensive assessment skills. (Medium proficiency) Licensure Registered Nurse, New York – New York State Board of Nursing Required. HC‑PRI Preferred. PRI Preferred. EEO Statement Montefiore Nyack Hospital is an equal employment opportunity employer. Montefiore Nyack Hospital will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law. #J-18808-Ljbffr 2300 Montefiore Nyack Hospital