Utilization Review Nurse (RN)

Description

JOB PURPOSE OR MISSION: Responsible for utilization of clinical and financial resources by: ensuring appropriate clinical level of care, performing and submitting clinical information to external payers to secure proper authorization, collaborating with the Care Coordinator in the development and implementation of the plan of care, serving as a primary resource to the Utilization Review Nurse I (LPN), and ensures prompt notification of any denials to the appropriate Care Coordinator, Denials/Appeals Coordinator, and Team Leader. Performs all job duties for the age population served, as defined in the department's scope of service.

PERFORMANCE CRITERIA

CRITERIA A: Everyday Excellence Values - Employee demonstrates Everyday Excellence values in the day-to-day performance of their job.

PERFORMANCE STANDARDS:

• Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
• Takes initiative in living our Everyday Excellence values and vital signs.
• Takes initiative in identifying customer needs before the customer asks.
• Participates in teamwork willingly and with enthusiasm.
• Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
• Keeps customers informed, answers customer questions and anticipates information needs of customers.

CRITERIA B: Corporate Compliance - Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines, and the GHS Corporate Compliance Guidelines.

PERFORMANCE STANDARDS:

• Practices diligence in fulfilling the regulatory and legal requirements of the position and department.
• Maintains accurate and reliable patient/organizational records.
• Maintains professional relationships with appropriate officials; communicates honesty and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.

CRITERIA C: Personal Achievement - Employee demonstrates initiative in achieving work goals and meeting personal objectives.

PERFORMANCE STANDARDS:

• Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
• Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
• Upholds the ethical standards of the organization.

CRITERIA D: Performance Improvement - Employee actively participates in Performance Improvement activities and incorporates quality improvement standards in his/her job performance.

PERFORMANCE STANDARDS:

• Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.
• Initiates or redesigns to continuously improve work processes.
• Contributes ideas and suggestions to improve approaches to work processes.
• Willingly participates in organization and/or department quality initiatives.

CRITERIA E: Cost Management - Employee demonstrates effective cost management practices.

PERFORMANCE STANDARDS:

• Effectively manages time and resources.
• Makes conscious effort to effectively utilize the resources of the organization - material, human, and financial.
• Consistently looks for and uses resource saving processes.

CRITERIA F: Patient & Employee Safety - Employee actively participates in and demonstrates effective patient and employee safety practices.

PERFORMANCE STANDARDS:

• Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.
• Employee proactively reports errors, potential errors, injuries or potential injuries.
• Employee demonstrates departmental specific patient and employee safety standards at all times.
• Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures and plans.

JOB FUNCTIONS

ESSENTIAL JOB FUNCTIONS include, but are not limited to:

1. Coordinates utilization of clinical and financial resources

PERFORMANCE STANDARDS:

• Identifies accurate payer information for each assigned patient.
• Communicates and collaborates with admission/precertification department to ensure appropriate payer precertification is completed for level of care status.
• Performs admission review on all assigned inpatients and observation patients within one business day of admission for appropriateness of admission and level of care based on medical necessity utilizing InterQual criteria.
• Refers appropriate cases to physician advisor or designee, communicating via Provider Link and/or telephonically.
• Communicates with admitting physician as needed to ensure the correct admit level of care status.
• Performs concurrent review on all assigned patients for appropriateness of level of care and continued stay based on medical necessity utilizing InterQual criteria as required by external payers.
• Contacts physician and/or Care Coordinator for additional information regarding cases not meeting medical necessity criteria for admission and continued stay reviews.
• Identifies and refers problem cases to appropriate Care Coordinator and/or supervisor.
• Maximizes reimbursement to BRGMC by:
  • Communicating pertinent clinical information to payers.
  • Helping to ensure that physician documentation supports current clinical level of care.
  • Communicating and collaborating with Intake Nurse/Care Coordinator to assist with appropriate interventions to avoid denial of payment.
  • Assisting in arranging peer to peer conferences to avoid denial of payment.
  • Assisting in denials/appeals processes.
  • Identifies and communicates to the Care Coordinator opportunities for more efficient resources utilization.
  • Serves as a primary resource to the Utilization Review Nurse I (LPN) by:
    • Assisting with cases that are not meeting medical necessity criteria for admission and continued stay reviews.
    • Communicating with external payers, physicians, and/or Care Coordinator when peer to peer conferences are needed.
    • Ensuring appropriate order is written by the physician, if the level of care is changed.
    • Assisting with cases that have been issued denials and/or rejections.
    • Collaborates with the Care Coordinator in the development and implementation of the plan of care.
    • Documents in Provider Link specific patient information received regarding level of care, authorizations and approved/denied days.
    • Communicates with payers regarding discharges by sending discharge notifications as appropriate.
    • Closes out each case once date of service authorization is complete.
    • Communicates with insurances specialist to ensure all authorizations are timely and complete.

2. Participates in quality improvement activities.

PERFORMANCE STANDARDS:

• Reports sentinel events and quality of care issues to the Director of Case Management.
• Collects and tracks data (denials, avoidable days, etc.) as determined by Supervisor and/or Director.
• Participates in performance improvement activities as needed.

3. Performs all other duties as assigned.

Requirements

EXPERIENCE REQUIREMENTS
Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge
of local and national coverage determinations.
Recent work experience in the hospital or insurance industry.

EDUCATIONAL REQUIREMENTS
Current Louisiana RN licensure

SPECIAL SKILLS, LICENSE AND KNOWLEDGE REQUREMENTS
Demonstrates knowledge of human behavior, socioeconomic factors in disease and illness,
behavior patterns of the physically and mentally ill patient.
Demonstrates outstanding communication skills and can establish constructive relationships with
patients, families, payers, and hospital associates.
Demonstrates advanced knowledge of regulatory and payer requirements as it pertains to level of
care, medical documentation, and medical necessity.
Works well under pressure of time and shifting priorities.
ACM or CCM certification preferred.

HIPAA REQUIREMENTS:
Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to the job position,
including but not limited to: Medical records without limitation of both paper and electronic, patient
demographics, lab and radiology results, patient information related to surgery or appointment schedules,
information related to patient location, religious beliefs and/or public health records, medical records
related to quality/data, patient financial information and/or 3rd party billing, patient-related complaints,
research information, employee health records and employee prescriptions.

SAFETY REQUIREMENTS:
Maintains knowledge of and adherence to all applicable safety practices appropriate to the job position,
including but not limited to: Incident reporting, PPE, exposure control plans, hand washing, environment
of care, patient identification.