Utilization Review RN - Per Diem*

POSITION SUMMARY Performs clinically oriented medical chart reviews and other administrative tasks to meet the requirements of the medical center's utilization review plan, state and federal regulations, insurance company requirements for reimbursement. *IMPORTANT NOTE: In lieu of benefits due to \"per diem\" status, 15% will be added to the hourly rate. Per diem employees are offered work on an \"as-needed\" basis. POSITION REQUIREMENTS Minimum Education A Bachelor's Degree in Nursing preferred; three (3) years of clinical care or nursing experience; OR an equivalent combination of education and experience AND (2) two years’ experience Utilization Review. Certificate Preferred CCM (certification in case management) is preferred. License Required Must be licensed as a Registered Nurse by the State of Nevada, and remain active with all annual licensing requirements. Minimum Work Experience Minimum of 1 year of case management or utilization management experience. Knowledge of InterQual or McKesson criteria preferred. Knowledge in conducting a medical record review for medical necessity. Knowledge of basic ICD-10, CPT coding knowledge preferred. Basic knowledge of regulations as set forth by The Centers for Medicare Medicaid Services. Skill in operating a personal computer utilizing a variety of software applications. Strong written and oral communication skills. Skill and ability to work independently. POSITION ESSENTIAL FUNCTIONS Chart Review Conducts chart review to determine that InterQual-based care criteria is met. Assist in determining if patients are in the correct hospital setting. Review elective surgery schedule. Review outpatient charts (observation). Obtain appropriate patient records as required by payor agencies and initiate the UR Medical Director as necessary for unwarranted admissions. Hospital Reimbursements Understand and demonstrates the requirements needed to maximize reimbursement to the hospital. Assist in obtaining authorizations as needed; including follow-up. Respond to insurance providers in a timely and thorough manner. Communicates with various hospital departments in a meaningful manner. Reviews denials and collaborates on appeals of denials. Communicates with HIM staff and resolves discrepancies. Assists in ensuring appropriate room charges, patient status, discharge disposition, etc. Knowledge Condition 44 documentation and requirement; HINN notification letters, ABN-advance beneficiary notice, Important Letter from Medicare, etc. Maintains practices consistent with the hospital's utilization review (UR) plan. Reviews the plan's components and is a member of the utilization review committee. Obtains data and statistics addressed in the hospital's UR plan and presents information as needed. Ensures appropriate and cost-effective healthcare services to patients. Documentation Demonstrates understanding and supports clinical documentation improvement strategies. Ability to efficiently locate priority clinical information in a medical record, and critically interpret that information as part of a treatment plan. Analyze clinical information to identify areas with potential for documentation improvement. Demonstrates collaborative work relationship with coding staff to assure documentation of discharge diagnosis and co-morbidities are complete and accurately reflect the patient’s clinical status and care. Reviews medical records concurrently, recognizes opportunities for documentation improvement, and follows up with appropriate staff. Facilitates modifications to clinical documentation through collaborative interactions with physicians, nurses, and ancillary staff. Per Diem positions have no guaranteed hours or set schedule. The position will fill in for individuals who take unplanned and/or planned time off. #J-18808-Ljbffr