This night-shift post on the cardiac ward pairs patient care with mentoring new nurses. The Utilization Review Nurse documents utilization review activity, performs concurrent and retrospective reviews, and communicates effectively with the healthcare team. This role involves collaborating with medical staff, hospital departments, and ancillary services to expedite care delivery and manage utilization management activities.
Responsibilities
Document utilization review activity per department and medical center standards in a timely manner
Perform and document accurate and timely concurrent and retrospective reviews based on approved established criteria
Communicate effectively with the healthcare team
Work closely with medical staff, hospital departments, and ancillary services as part of the Outcome Facilitation Team/Multidisciplinary Team in expediting care delivery to avoid delays in timely service provision and implementing and reporting utilization management (UM) activities, as applicable
Collaborate with managers, physicians, medical directors, advisory groups, and treatment teams for issues related to physician practices and best practices for the patient’s plan of care
Refer cases to physician advisor as needed to ensure accurate status and compliance with regulatory guidelines
Remain knowledgeable in issues of healthcare regulations, reimbursement issues, impact on length of stay, and community resources
Provide clinical updates to payers and/or external review organizations, collect data, coordinate denial activity, support UM activity, and manage avoidable delays
Develop and maintain productive relationships with community-based agencies and networks by representing Aurora Health Care in a positive manner, working collaboratively, internally and externally, to meet patient/family needs
Serve as an educator and expert resource to medical and hospital staff regarding admission status and acute care criteria, utilization management issues, and relevant regulatory requirements
Demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served
Demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures
Requirements
Registered Nurse license issued by the state in which the team member practices
Bachelor's Degree (or equivalent knowledge) in Nursing
Typically requires 3 years of experience in clinical nursing, utilization and/or quality management
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Working knowledge in the use of Microsoft Office (Excel, Outlook, PowerPoint and Word) or similar products
Knowledge of the components of quality and acute care patient care needs specifically related to the area/function in which care management will be performed
Working knowledge of Utilization Review criteria as demonstrated by achieving 80% or greater on the annual Inter Rater Reliability (IRR) competency exam
Critical thinking skills to analyze and synthesize clinical scenarios as it relates to application of medical necessity criteria
Excellent analytical and interpersonal communication skills necessary to interact with families, patients, physicians, and third party payers
Ability to manage conflict appropriately, seeking a win-win outcome by communicating issues in accordance with the Aurora Service commitments
Promote effective professional relationships with physicians and other professionals in a direct and positive manner
Take responsibility for self-development by seeking out opportunities for professional growth and development and being an active participant in department, hospital, and system initiatives
Important Details
Schedule: ZERO HOUR, 2 shifts per week, every 5th weekend, 1 summer holiday, 1 winter holiday
About the Company
Advocate Aurora Health Corporate is a healthcare organization with a focus on Utilization Management.
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