RN Utilization Review / Case Manager - Full Time - Day Shift

Hospital - Hawkinsville

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Position Description

The goal of this position is to control costs while monitoring the quality of patient care. Utilization Review nurses critically examine patient medical records, paying close attention to the appropriateness of healthcare expenditures. They rely on their experience, education, and awareness of appropriate review criteria to compile an accurate account of the patient’s clinical picture.

Job Duties:
Provide quality utilization case reviews.

Monitor hospital resource utilization processes for all patients.

Knowledgeable and able to effectively utilize medical necessity monitoring tools, hospital approved level of care guidelines, and or any payer specific guidelines or contractual obligations.

Evaluates documentation on patient’s medical necessity elements and appropriateness of scheduled and direct/emergent admissions, surgeries, and other procedures/tests.

Utilizes professional nursing knowledge to ensure that admissions and length of stay are reviewed as medically justified, and the physician’s decision-making and judgment documentation is within the patient’s medical record.

Collaborates with physicians, and clinical staff to ensure resource utilization is appropriate to the patient’s clinical needs during hospitalization, and discharge planning needs, within covered payer benefits, when necessary.

Collaborates with payer specialists, hospital discharge planners, care managers, physicians and other members of care team in order to identify, develop, and implement successful communication, education, and processes to increase staff engagement, and promote optimal clinical utilization of resources.

Functions as an advocate, and contact person for the care team, patient/family when communicating with payers, and or outside agencies to assure continuity of care, optimal clinical resource outcomes, and appropriate financial management for the patient and the organization.

Ensures initial admission reviews are completed and submitted to payer in a timely manner, same admission day or within first working day of admission; obtain certified days for patient’s presenting signs and symptoms and or documented primary diagnosis with treatment plan with the confirmation of level of care and admission status (patient type) appropriateness throughout the patient’s hospital stay.

Current Licensure, Minimum 2 years Experience as a Registered Nurse in an acute care hospital required, EMR/EHR Experience, Utilization Review, Resource Management, Care Coordination, Transitional Planning, Hospital Denials and Appeals, Experience in Managed Care, Commercial Payer Guidelines, Clinical Skills, Bedside Manner, Infection Control, Nursing Skills, Physiological Knowledge, Administering Medication, Medical Teamwork, Multi-tasking, Listening, Verbal Communication, Health Promotion and Maintenance