Utilization Review Nurse (U)

Overview Case Manager RN (U) coordinates the overall interdisciplinary plan of care for patients from admission to discharge. Monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers. Develops a discharge plan that provides the best available resources to meet ongoing patient needs and encourages compliance with medical advice. Identifies patient care issues and suggests revisions to or new clinical pathways to improve quality of care. Care facilitation for all assigned patients includes extended recovery, outpatient observation and inpatient admissions to include care progression, timely consultations and testing facilitation, assure social service intervention and individual discharge planning that reflects the patient’s assessed needs, insurance coverage benefits, and organizational capabilities. Responsibilities Incorporate the fundamental principles of monitoring resource consumption and capture of avoidable days. Enter Ancillary notes utilizing the templates for care facilitation. Proactively ensure orders are obtained and facilitate delivery of clinical and community services to patients and families through effective utilization of available resources. Attend daily multidisciplinary huddles, contribute to meeting facilitation and progression of care. Ensure the appropriateness and cost effectiveness of the patient’s plan of care based on DRG. Collaborate with physicians to develop patient care plans and review medical needs for continued hospital services and resource consumption. Utilize case manager nurse-driven protocols to facilitate care and request physician orders for items not part of CM nursing protocol. Provide required Medicare documents to the patient and/or proxy when applicable, including discharge Important Message from Medicare, Code 44 patient notification documents. Process QIO Medicare appeals. Coordinate acute care transfers including psychiatric transfers. Attend and facilitate daily multi-disciplinary huddles and report on LOS outliers and complex case reviews as assigned. Communicate daily with management on observation outliers related to care transition and discharge barriers. Identify patient risk factors or obstacles to care, discharge, and readmission. Evaluate the plan of care regularly by chart review and patient interviews; collaborate with the medical team to facilitate movement through the system. Educate patients and families on the progression of care. Serve as a liaison between patients, families, and healthcare personnel to ensure necessary care is provided promptly, effectively, and in a fiscally responsible manner. Promote quality care to ensure patients receive medically appropriate services in appropriate status and stay standards. Facilitate regulatory notifications and patient signatures per policy. Maintain knowledge regarding insurance reimbursement policies. Rely on experience and judgment to plan and facilitate discharge and transition plans, ensuring they meet the physical, social, and emotional needs of the patient. Adhere to University and unit-level policies and safeguard University assets. Qualifications Education: Bachelor’s Degree in relevant field Certification and Licensing: Registered Nurse Licensing (RN) Experience: Minimum 7 Years Of Relevant Experience (5 years of case management/utilization review experience) Knowledge, Skills and Attitudes: Ability to communicate effectively in both oral and written form. Ability to recognize, analyze, and solve a variety of problems. Ability to analyze, organize and prioritize work under pressure while meeting deadlines. Ability to maintain effective interpersonal relationships. The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more. The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Job Details Job Status: Full time Employee Type: Staff #J-18808-Ljbffr