The Utilization Review Nurse is a registered nurse who: provides clinical review against industry recognized criteria for the purpose of evaluating medical necessity for hospitalization, regardless of payer type; provides feedback and assistance with other members of the healthcare team regarding appropriate use of resources and timely follow-through with the plan of care; provides ongoing communication with various insurance providers regarding medical necessity for prospective, concurrent, and retrospective reviews; intervenes when potential denials are determined and facilitates appeals when concurrent denials are received; partners with physicians related to appropriateness of admission and the prevention of denials. Performs the essential functions of the Utilization Review RN.
Perform initial, concurrent, discharge and retrospective reviews on all patients, per policy.
Review clinical information for appropriateness and correct admission status (inpatient, observation, out-patient in a bed.) Ensures appropriate MD order is in place for billing purposes.
Work closely with Registration staff to insure insurance notification, initial authorization and elective surgical CPT codes are accurate and coincide with MD status orders.
Develop rapport and communicate directly with insurance companies and/or payer to obtain admission and continued stay certification or recertification.
Facilitate MD peer to peer for concurrent medical necessity denials.
Track and fax reviews per policy and as needed to ensure certification of days.
Collaborate with attending/hospitalist and notifies the Medical Director on patients not meeting criteria and informs Director.
Monitors for 1MN stays and ensures Condition Code 44 is completed, as indicated.
Communicates identified patients who do not meet criteria to Case Managers for discharge planning.
Compiles a concurrent list of insurance contacts and assists hospital case managers with coordinating discharge needs with insurance discharge planners, as indicated.
Communicates identified problems or trends with insurance companies to Director.
Identifies the need for professional growth and seeks appropriate development opportunities.
Stays current with CMS/Medicare rules and seeks appropriate opportunities to remain knowedgeable and current.
Education: Associate Degree in Nursing required/Bachelors degree preferred
Experience: Minimum of three years recent Utilization Review experience preferred
Certifications: License: RN; Certification in Case Management, preferred
Preferred: Knowledge in Milliman/InterQual criteria application, preferred