Utilization Review RN - Utilization Resource Management

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$40.99 - $53.56

Scheduled Weekly Hours:

40

Position Overview

Performs a variety of utilization and resource management activities to promote quality, clinical and cost effective outcomes. Assesses patients treatment plans, communicates to third party payers, and collaborates with healthcare team members. Performs functions which help to optimize lengths of stay, utilize resources efficiently, and promote cost effective practices without negatively impacting patient care. Adheres to established standards, practices and procedures.

MINIMUM REQUIREMENTS

Education: Associate's degree in nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred.

Experience: Five years' clinical nursing and three years quality management, utilization review or discharge planning experience.

Other Credentials: Registered Nurse - NJ

Knowledge and Skills:

Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines.

Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Usual Work Day: 8 Hours

Reporting Relationships

Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS

Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care.

Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination.

Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. .

Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry.

Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians.

Understands and applies federal law regarding use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters.

Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in Utilization software program.

Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels.

Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources.

Recognizes and responds appropriately to patient safety and risk factors.

Represents Utilization Management at various committees, professional organizations an physician groups as needed.

Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care.

Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in patient population.

Participates in performance improvement activities.

Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay.

Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes.

Maintains appropriate documentation in Utilization software system on each patient to include specific information of all resource utilization activities.

Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care.

Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols.

Performs other duties as needed.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Sitting , Standing , Walking

Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 15 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing

Anticipated Occupational Exposure Risks Include the following: N/A

IND123.

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.