About This Role
This nursing position focuses on utilization review activities, ensuring timely documentation and accurate concurrent and retrospective reviews based on established criteria. The role involves close collaboration with medical staff, hospital departments, and external organizations 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
- Prior UM experience
- 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
- Working knowledge in the use of Microsoft Office (Excel, Outlook, PowerPoint and Word) or similar products
