Patient care & utilization review rn

Utilization Review Specific

• Gathers pertinent clinical information and applies and interprets criteria to ensure medical necessity, covered benefits, participating providers, and appropriate services.
• Advocates that the patient is placed in the appropriate level of care and program.
• Interfaces with program staff to facilitate a smooth transition at the time of transfer or discharge.
• Monitors patient charts and records to evaluate care concurrent with the patient’s treatment.
• Reviews treatment plans and status of approvals from insurers.
• Facilitates and coordinates discharge planning and works towards reduction of preventable hospital admissions, re-admissions, etc.
• Works closely with Revenue Cycle Department to ensure the insurance precertification process is complete and to update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
• Collects and compiles data as required and rendering with applicable hospital policies as well as state and federal guidelines.
• Communicates with clinical care team with any outstanding or concerning findings during utilization review including, but not limited to: failure to meet medical necessity, inappropriate admission status, etc.
• Communicates with providers to obtain any medical record documentation necessary to perform utilization review.
• Documents any UR needs or notes into Electronic Medical Record (EMR).
• Administers or participates in audits of programs to ensure agency compliance on utilization review regulations.
• Performs other duties as assigned.
• Organization
• Wide
• Performance
• Expectations:
• Demonstrates 100% commitment to performing according to the CHOICE values of MRH and representing the organization in a positive and professional manner.
• Establishes and maintains effective verbal and written communication and good working relationships with all patients, staff and vendors.
• Adheres to MRH attire/dress code per policies and procedures.
• Utilizes initiative; strives to maintain steady level of productivity; self-motivated; manages activity and time.
• Completes annual education, training, in-service, and licensure/certification requirements; attends departmental and organizational staff meetings or reads meeting minutes.
• Maintains patient confidentiality at all times.
• Reports to work on time as scheduled; completes work within designated timeframes.
• Actively participates in departmental and facility performance improvement and continuous quality improvement activities.
• Strives to uphold regulatory requirements to ensure continual compliance with departmental, hospital, state and federal regulations and policies.
• Follows policies and procedures for infection control, safety, and risk management to ensure a safe environment for patients, public, and staff.

Qualifications

• Minimum Requirements:
• Must be at least 16 years of age (21 for driving positions).
• Must be able to legally work in the United States.
• Must be able to pass a background check.
• Must be able to pass a drug screen and breath alcohol test (if applicable).
• Must complete employee health meeting. Required Education/Licensure/Certification:
• Unencumbered Colorado or Compact State RN License, preferred or LPN License OR
• Masters in Social Work or related field, preferred.
• Current BLS certification (or must be obtained within 90 days).

Experience

• Minimum two (2) years of experience in an acute care setting, preferred.