[Hiring] Lead Utilization Review RN @Ensemble Health Partners

Role Description

The Lead Utilization Review RN is a key contributor to the overall financial, quality, and clinical performance of the organization. The Lead UR supports an outcomes-oriented, patient care delivery system, which places the patient at the center of all activities. The Lead UR facilitates the improvement of overall quality and completeness of medical record documentation. They work to provide a positive financial impact to the institution through extensive interaction with physicians, nurses, other patient care givers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete. Monitors and evaluates care to ensure costs are medically necessary, provided in the appropriate setting, and are generated according to governmental and regulatory agency standards.

Job Responsibilities

• Resource Utilization:
  • Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services.
  • Initiates appropriate referral to physician advisor in a timely manner.
  • Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with hospital liaison.
  • Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payers.
• Medical Necessity Determination:
  • Conducts medical necessity review of all admissions daily.
  • Utilizes approved clinical review criteria to determine medical necessity for admissions including appropriate patient status and continued stay reviews, possibly from an offsite location.
  • Provides inpatient and observation (if indicated) clinical reviews for commercial carriers within one business day of admission.
  • Communicates all medical necessity review outcomes to hospital liaison.
  • Collaborates with the liaison to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of care.
• Denial Management:
  • Coordinates the appeal process with the liaison, Financial Clearance Center, Revenue Cycle team when necessary and when assigned.
  • Maintains documentation relevant to the appeal process.
  • Assists in recording denial updates; overturned days and monitor and report denial trends that are noted.
  • Monitors for readmissions and report possibilities for readmission and current readmissions to the liaison.
• Discharge Planning:
  • Through the medical record review, evaluates for discharge planning needs of patients and makes appropriate and timely referrals to the care team and/or liaison.
• Quality/Revenue Integrity:
  • Demonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicators.
  • Accurately records data for statistical entry and submits information within required time frame.
  • Responsible for ConnectCare and ADT work queues assigned to case management for revenue cycle workflow.
• Facilitation of Patient Care:
  • Prioritizes patient care needs based on situational analysis, functional assessment, medical record review, and application of clinical review criteria.
  • Collaborates with the liaison in developing and expanding the plan of care to encompass multidisciplinary patient care needs.
  • Maintains rapport and communication with the liaison to monitor and evaluate the plan of care.
• Communication:
  • Directs physician and patient communication regarding non-coverage of benefits to the liaison.
  • Maintains positive, open communication with the physicians, nurses, multidisciplinary team members, liaison and administration.
  • Educates hospital and medical staff regarding case management program.
• Team Affirmation:
  • Works collaboratively with peers to achieve departmental goals in daily work.
  • Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities.
• Other Job Functions:
  • Complies with hospital and department policies and procedure, including confidentiality and patient’s rights.
  • Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
  • Actively participates in departmental meetings and activities.

Qualifications

• Current unrestricted RN license is required.
• 5+ years of nursing experience in an acute care environment required.
• Experience in utilization review/discharge planning.
• Recent and working knowledge of medical necessity review criteria experience preferred.
• Strong clinical assessment, organization and problem solving skills.
• Strong technical skills including database and spreadsheet analysis.

Requirements

• Bachelor's degree in Nursing preferred; Associate's degree in Nursing required.
• Ability to communicate ideas and thoughts effectively verbally and in written form.
• Able to participate collaboratively with all members of the care team.
• Ability to organize information quickly and effectively; prioritize and complete multiple tasks effectively.

Benefits

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• Pay Scale: $39.40/hr - $53/hr based on experience