Utilizatiion Review Nurse

: Employment Type: Full time Shift: Description:

GENERAL SUMMARY: Responsible for the review of inpatient and outpatient admission records for appropriate admission status at Mercy Medical Center and Mercy West Lakes. Works in collaboration with the attending physician and the Case Management staff utilizing admission criteria guidelines-and second level physician review process when appropriate. Interacts with insurance providers to obtain authorization and continued stay approval for admission. Collaborates with the Verification department, Revenue cycle and Financial Counseling to facilitate the establishment of the correct payer source for patient stay and the documentation of the interactions in the STAR admitting system.

ESSENTIAL FUNCTIONS: • Conducts admission review per the Utilization Management Plan to ensure that the hospitalization is warranted based on established criteria. Reviewing may be both concurrent or post discharge. • Carries out hospital programs and principles of utilization review in compliance with hospital policies and external regulatory agencies Peer Review Organization (PRO), Joint Commission, and multiple payer defined criteria for eligibility. • Applies Milliman Careguidelines Criteria for appropriate status determination. • Engages in discussion with the attending physician for clarification and/or status correction. • Engages second level physician review as indicated to support the appropriate status. • Ensures timely communication with Case Management staff for all concurrent status changes. • Administers Notice of Status Change to the patient/family when indicated. Provides education and information for the patient/family for clarification of the change. • Documents in the MR (Spell out) Utilization Management forms accurately to reflect the appropriate admission criteria and appropriate status along with any communications. • Ensures timely notification to Admitting of status of change or status discrepancies identified. • Reviews the records on admission for status orders present addressing CMS (spell out) rules and guidelines around admission status. 2 • Monitors insurance coverage for patients in the STAR admitting/financial system and communicates any updates to the Verification Department. • Provides clinical information as request from the insurance payer via telephone or fax in a timely manner to prevent technical denials. • Enters authorization, approvals and denials into the STAR systems and communicates pertinent changes to Case Management. • Engages the attending physician to advocate and communicate via Peer to Peer Review for discussion with insurance for admission, continued stay or status when required.

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED: • Current licensure as a registered nurse in the State of Iowa.

• Five (5) years clinical nursing experience.
• Bachelor of Science - Nursing or degree in healthcare-related field preferred.
• Knowledge of eligibility requirements for insurance coverage with respect to health care services: ambulatory, observation stays, surgical, acute care, subacute and continuum of care services.
• Demonstrated ability to manage complex management and clinical situations. Ability to work within a function independently exercising judgement to reach resolutions to issues.
• Specialty certification within 12 months of hire.

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