Utilization Review RN (PT)

POSITION SUMMARY

The UR R.N. is responsible for the daily continuity of patient care and effective utilization of health care services through case management, chart audit, discharge planning, and patient education in compliance with all federal and state regulations and payer requirements. Works with a multidisciplinary team of clinical and non-clinical providers and staff to ensure the patient is receiving the highest quality of care in the appropriate setting.

POSITION QUALIFICATIONS

Education: Graduation from an accredited School of Nursing. BSN preferred.

Experience: Requires the ability to understand medical record documentation for all clinical disciplines. Experience with a CDM preferred but not required.

Licenses/Certification: Current Colorado R.N. license in good standing. Maintenance of current CPR or BLS.

ESSENTIAL FUNCTIONS

Observes professional ethics in maintaining confidential information concerning the personal, financial, medical, or employment status of a patient of GVH and their families.

Concurrently analyzes all inpatient, observation, and outpatient in a bed cases for medical necessity of continued stay and provides feedback to providers for required supporting documentation as necessary per Federal, State, and commercial payer guidelines.

Provides daily consultation to professional staff and employees regarding patient stay options, financial considerations, psychosocial concerns, risk management, and ethical issues for all patients who are in-house.

Communicates with insurance companies on a daily basis by ensuring that precertification requirements for each payer are met by providing treatment plans and medical records, updates to patient status are completed, and that authorization numbers are obtained as required.

Audits documentation and charges for inpatient, observation, outpatient nursing, surgery, obstetrics, swing bed, and emergency cases on a daily basis based on criteria established for each type of patient.

Maintains and updates the observation hours and outpatient in a bed hours logs on a daily basis.

Makes charge adjustments as required based on chart audit results and in collaboration with key stakeholders in the revenue cycle.

Communicates case management recommendations and activities with the multidisciplinary team on a daily basis.

Develops discharge plan in coordination with the multidisciplinary team and in consideration of the providers medical plan of care.

Identifies educational needs of the patient and family and provides for the appropriate resources and information.

Communicates interdepartmentally to integrate UR activities into the revenue cycle and hospital systems.

Provides feedback to the UR RN Supervisor to ensure the department processes are continually improving.

Communicates issues to the UR RN Supervisor in a timely and appropriate manner.

Enhances professional growth and development through participation in professional organizations, educational programs, current literature, in-services, meetings, and workshops.

Maintains a positive working relationship with Administration, Directors, physicians and their office staff, hospital staff, and vendors to ensure goals are optimized and that good working relationships are cultivated and retained.

Participates in drills and emergency response training and may be called in for GVH disaster response.

Other duties as assigned.