About This Role
This role focuses on maximizing the quality and cost efficiency of healthcare services by ensuring patients receive necessary care without unnecessary procedures or extended hospital stays. The utilization review nurse relies on extensive knowledge of patient care, medical treatments, and hospital procedures, using clinical judgment to promote patient health and well-being while managing resources. The role also involves assisting Registered Nurse (RN) Case Managers and Social Workers by educating patients on their healthcare coverage.
Responsibilities
- Utilize electronic healthcare record (EHR) and billing systems, filter and prioritize UM Worklist, document Utilization Management (UM) reviews of various types, enter notes, locate insurance information, provide clinical updates to third-party payors, place accounts on hold and release, and manage concurrent denials
- Proficiently navigate within the EHR and the UM platform to gather documented information concerning the patient to establish appropriate utilization of hospital services
- Conduct and document a UM Review at the time of admission or the next working day
- Conduct and document concurrent UM reviews no more than 3 days after the admission review has been completed, referring to the Physician Advisor appropriately
- Perform an in-depth Extended Stay review on patients with a stay greater than 5 days and refer to the Physician Advisor appropriately
- Utilize and apply UM platform Care Level Scores along with clinical expertise to validate the medical necessity of the ordered admission status, appropriateness of treatment, and ordered level of care
- Confer with the attending physician or Physician Advisor when appropriate to make a determination about medical necessity
- Communicate and work closely with insurance companies to ensure that the organization will be reimbursed for services rendered, providing supporting documentation to justify the medical necessity of the admission or continuation of stay
- Assist and educate Medical Staff and other members of the healthcare team regarding utilization issues such as, but not limited to: Admission Status, Level of Care, Medical Necessity, Costs and best practices of treatment, Expected Length of Stay (LOS)
- Function as a resource to the healthcare team regarding approved criteria, practice guidelines, and alternative treatment options
- Provide monthly reporting to the Utilization Management/Case Management Committee regarding inappropriate admissions
- Assist with ensuring compliance with CMS Conditions of Participation for Utilization Review, Appendix A/§42 CFR 482.30
Requirements
- Current State of Texas License as a Registered Nurse
- 5 years of nursing experience (preferably in utilization management or hospital/acute care)
- Computer proficiency in Microsoft Office
