RN Utilization Review Specialist

Location & Working Hours City/State: Nyack, New York Department: Care Management Work Shift: Day Work Days: MON-FRI Scheduled Hours: 9 AM-5:30 PM Scheduled Daily Hours: 8 HOURS Hours Per Pay Period: 40 Pay Rate/Range: Starting at $110,000 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, consider payer requirements and responds accordingly to avoid adverse financial consequence to patient and hospital. Provide superior customer service by modeling the We Care Standards. Essential Functions 1. 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. 2. 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 (patients, visitors, families, physicians, staff, etc.) 3. 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. 4. 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. 5. 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. As appropriate for discipline (Registered Nurse versus Social Worker). 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. 6. May take orders from physicians including but not limited to discharge orders. 7. Conducts clinical reviews utilizing objective criteria (Interqual) to assign patient to the appropriate level of car; identifies clinical resources required to achieve optimal patient outcomes and appropriate reimbursement for the hospital. 8. Documents level of care and medical necessity in the Care Management database to support the clinical review process. 9. Concurrently monitors resource utilization, performing continued stay reviews and assists with managing length of stay of patients. 10. Concurrently 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. Qualities that include effective written and verbal communication skills, decision-making and problem-solving skills, and comprehensive assessment skills. (Medium proficiency) Registered Nurse New York - New York State Board of Nursing Required HC-PRI Preferred PRI Preferred 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. If you’re a skilled healthcare professional who values teamwork and excellence in patient care, then Montefiore Nyack Hospital could be your perfect match. As part of the Montefiore Health System, we offer the quality of a premier academic medical center and the caring of a community hospital. We’re committed to the health and well-being of Rockland County’s residents and our team members, and offer flexible opportunities for per diem, part-time and full-time employment. Benefits Robust compensation package, including competitive pay, medical benefits, tuition reimbursement and more Outstanding professional staff The clinical excellence of the Montefiore Health System Opportunities for growth through training and continuing education Equal Opportunity Employment Zero tolerance policy for discrimination, harassment and abuse Fair employment practices, including equal treatment in hiring, promotion and compensation WE CARE code of conduct for all team members ust 35 miles from New York City, Rockland County offers friendly communities, natural beauty, outdoor pursuits, convenient shopping and easy access to New York City. While Rockland County has plenty to offer, both the mountains and the beach are within a few hours’ drive. Rockland is an area full of history and has a vibrant arts scene with museums, theaters, music venues, cultural events and festivals. Learn more about cultural events in Rockland County. With over 3,000 acres of parks, Rockland County is a Preserve America Community protecting open spaces and uncluttered skylines. The county offers trails, dog runs, historic landmarks, water activities, golf and horseback trails. Learn more about outdoor activities in Rockland County. One of the top dining areas in the Hudson Valley, Rockland County features award-winning chefs and a growing craft beverage scene. Shopping options range from independent boutiques in quaint downtowns to the Palisades Center mall, a four-level shopping experience. Learn more about dining and shopping in Rockland County. Safe, thriving communities with outstanding schools and healthcare make Rockland County ideal for both professionals and families. Whether you’re growing your family and looking for good schools and family-friendly neighborhoods or growing your career and looking for higher education opportunities close to home, Rockland County has what you need. #J-18808-Ljbffr Montefiore Nyack