Utilization Management Nurse

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Work Shift

Day (United States of America)

Job Summary:

The Utilization Management (UM) Nurse is responsible for conducting medical necessity reviews up to 12 hours per day, on any of the 7 days per week, utilizing Indicia for Case Management, and performs clinical reviews through document review, discussion with physicians and collaboration with the care team on the coordination of safe transitions of care for a defined patient population. The UM Nurse will perform utilization review every day by looking at all new admissions, all observation cases and concurrent reviews. They will be assigned to specific units/and or payer/and or patient class. All clinical reviews will be done by utilizing mcg Indicia, Indicia for Admission Documentation (IAD), and Indicia for Effective Focus (IEF) criteria in conjunction with medical records documentation and communication with physicians and physician's advisors. The UM nurse gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to complete the determination/recommendation for the most appropriate level of care status and shares pertinent clinical information to the payers. Along the continuum of care, the UM Nurse communicates with providers and other parties to facilitate care/treatment. UM Nurse identifies opportunities to ensure effectiveness of healthcare services in the most appropriate setting always, as well as timely discharge to the most appropriate level of post discharge care. The UM Nurse obtains timely authorization of all ALOS days from payers and ensures accurate and complete documentation in the appropriate place in EPIC to enable timely billing. UM RN monitors post-discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. The UM Nurse communicates with third party payors to resolve discrepancies prior to billing, accurately and concisely documents all communications regarding and actions taken on the account in accordance with policies and procedures, and escalates medical review request and/or denial activities to management as needed. UM Nurse works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no authorization numbers, ALOS vs. authorized days, or other discrepancies. The UM Nurse evaluates clinical documentation in patient records and escalates issues through the established chain of command. UM Nurse tracks avoidable days accurately in the avoidable day module in EPIC per department Standard Work and performs accurate and timely documentation of all review activities.

Core Responsibilities and Essential Functions:

Utilization Management * Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG). * Ensures timely identification of need and referral for alternative level of care. * Responsible for timely and accurate certification/authorization of hospital admissions and hospital days * Provides required information to payors in a timely fashion and obtains appropriate authorization for all days. Ensures authorizations are documented in EPIC in a timely manner. * Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards, utilizing screening criteria to determine level of care with documentation. * Monitors and evaluates the appropriateness of managed care denials and collaborates with attending physician, physician advisors and managed care representative to overturn denials. * Monitors for compliance of Medicare/Medicaid regulations * Advocates for patient and negotiates and refers for services that maybe required outside of patients health care coverage. * Identifies, participates, and supports continuous performance improvement initiatives based on identified opportunities. * Ensures appropriate compliance with payer regulations and that all information is well documented to prevent payer disputes and denials. Assessment * Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG) * Assesses insurance and coverage requirements for all payers and ensure adherence to those requirements at all time. * Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution. Documentation and Post Discharge * Completes chart notes accurately and on time per Departmental protocol. * Ensures all records are up-to-date. * Ensures timely and accurate documentation of clinical reviews and insurance updates as required by payor including authorized days and denied days with reason for denial * Works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no auth numbers, ALOS vs. authorized days or other discrepancies. * Evaluates clinical documentation in patient records and escalates issues through the established chain of command. Professional Development and Initiative * Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. * Serves as a preceptor and/or or mentor for other professional and/or students Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years Strong clinical knowledge with clinical practice/experience Required

Required Minimum Skills:

Knowledge of Case Management process. Low Excellent verbal and written communication skills. Medium Strong organizational skills. Medium Ability to build strong and trusting relationships with physicians and the multidisciplinary team. Medium Knowledgeable with utilizing screening criteria in review of clinical data and identifying variance. Low Ability to critically think and analyze information, effect change, and effectively impact timely throughput. Medium Strong computer skills required. Medium

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