UTILIZATION REVIEW NURSE - CASE MANAGEMENT
Status: Full Time
Shift: M-F 7a-3:30p with alternating holiday coverage
Exempt: No
Other information:
A. EXPERIENCE, KNOWLEDGE, AND SKILL
1. Previous Experience Required
a. Minimum of 5 years relevant nursing experience in acute care settings required.
b. Utilization Review experience preferred and can be substituted for clinical nursing experience.
2. Specialized or Technical Education Requirements
a. Licensed Practical Nurse or Registered Nurse currently licensed to practice in the State of Louisiana required
b. Knowledge of Prospective Payment System, DRG’s, preferred.
c. Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations preferred.
3. Manual or Physical Skills
a. Basic Computer skills preferred.
4. Physical Effort Required
Strength: Sedentary
Push: occasionally
Pull: occasionally
Carry: occasionally
Lift: occasionally
Sit: frequently
Stand: frequently
Walk: frequently
B. WORK COMPLEXITIES
1. Complexity and Difficulty
a. Demonstrated advanced communication and interpersonal skills with all levels of internal and external customers, including, but not limited to Medical Staff, patients, caregivers, clinical personnel, support, and technical staff, outside agencies, and members of the community.
b. Must be able to assist in implementation of regulatory changes of outside agencies, such as Centers for Medicare and Medicaid Services (C.M.S.), Conditions of Participation, Utilization Management, Quality Improvement Organization (Q.I.O.)., Joint Commission on the Accreditation of Healthcare Organizations (J.C.A.H.O.), and the Office of Community Services (O.C.S.).
c. Must be able to function well under high stress.
2.Seriousness of Errors
a. Improper interpretation and application of screening criteria could result in admission and/or continued stay denials.
b. Errors in referrals resulting in possible communication delays may cause the patient to suffer personal inconvenience; health related problems, and / or financial burden. Delay in procurement of services and equipment may necessitate rework to correct.
c. Failure to closely monitor utilization of services could result in over or under utilization of hospital services and have a negative impact on quality of care and / or financial outcomes.
C. WORKING CONDITIONS
1. Hazards
Hazards related to this position are minimal.
2. Adverse Working Conditions
Minimal adverse working conditions related to this job.
D. Contacts
1. Contact With Patients, General Public and Other Organizations
Contact with physicians, physician office personnel, patients, caregivers, and outside agencies is frequent. There is constant personal and telephonic communication required with physicians, their offices, insurance companies, other agencies, patients, and caregivers. Must possess excellent communication skills and maintain all professional ties to ensure the smooth function of the position.
Contacts with other hospital departments is frequent. Must maintain close relationship with Officers, Department Directors, Coordinators, and employees in all departments.
E. Responsibilities
1. Responsibility for Safety of Others
Responsible for thorough knowledge of all hospital safety policies and procedures as related to Case Management personnel.
2. Responsibility For Hospital Funds or Property
Function with cost containment in mind.
Compliance with hospital policies and procedures.
Maintain department functions based on budgetary guidelines.
Responsible to ensure all equipment, cell phones, computers, faxes, printers, telephones, beepers, and other equipment are utilized in accordance with established hospital policy.
3. Responsibility For Confidential Information
Maintains confidentiality of employee information
Maintains confidentiality of clinical patient information
Maintains confidentiality of Case Management Program data
4. Responsibility for Performance of Work without Immediate Supervisor
Must be able to function at a high level of performance at all times with or without the presence of the immediate supervisor. Must exercise excellent judgment in knowing when to contact and involve department supervisor, coordinator, director or officer in decision making.
5. Responsibility for Supervision of Others
The Utilization Review Nurse does not supervise any employees. However, any discrepancies in policy or the performance of policies dealing with the continuum of care for our patients should be noted and called to the attention of the Case Management Director
Responsibilities:
Monitors and facilitates initial and continued stay requirements and expectations with payers and the hospital.
1. Provides front-end revenue cycle through a pre-certification and access to care strategy through collaboration with the ED utilization review/case management team.
2. Applies medical necessity, severity of illness/intensity of service criteria for patients seeking inpatient admission or continued stay using nationally recognized clinical guidelines.
3. Performs admission reviews to ensure appropriate utilization of resources and level of care determination.
4. Educates members of the patient’s healthcare team on the appropriate access to and use of various levels of care.
5. Promote use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.
6. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44).
7. Promote medical documentation that accurately reflects intensity of services, quality and safety indicators and patient’s need to continuing stay.
8. Pro-actively participate as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient’s preference, reason for admission, and availability of resources.
9. Consults with physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
10. Communicates clinical review information to all third-party utilization review companies as per established policies and procedures to ensure continued benefit coverage for patients.
11. Performs needed concurrent and retro reviews and obtains authorizations.
12. Ensures consistent data capture to identify trends/problems related to delivery of care delays and potentially avoidable days.
13. Escalates appropriate cases to departmental leadership or physician advisor for additional support and guidance.
14. Supports the revenue cycle team by addressing denials related to medical necessity.
15. Manages Work Queues as assigned for Retro reviews, claim edits, and any other assigned correspondence with the business office.
Is an active member of the case management department and the North Oaks team
1. Fosters positive internal and external customer relations.
2. Participates in performance improvement activities as needed. Which include regular UR team meetings and may be asked to provide case reviews for internal process improvement initiatives.
3. Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
4. Provides orientation and mentoring to new staff.
5. Follows North Oaks Health System’s Compliance Programs and federal and state regulatory guidelines.
6. Other duties as deemed necessary and appropriate.
