RN, Utilization Review & Case Management

uoflhealth; Louisville (KY); On-site; USD 75,000 - 105,000; Full time

Job summary

UofL Health in Louisville, KY is seeking a Utilization Review RN to support utilization management by assessing medical necessity for admission and continued stay, screening patients per guidelines, and coordinating with physicians and case managers to secure payor approvals.

The role requires documenting in Case Management Software, identifying delays, promoting efficient resource use, and educating clinicians about payer rules, with a commitment to patient-centered care and compliance with UM

Responsibilities

• Promotes optimal management of clinical resources by conducting timely admission and concurrent utilization review for all patients of designated medical services; certifies medical necessity for admission, continued stay and discharge reviews for patients certified by utilizing the current MCG criteria; documents clinical information in Case Management Software system
• During the concurrent review process, evaluates the medical record to identify any process delay impacting the timeliness of patient care in a collaborative effort to ensure that the appropriate resources are utilized (i.e. physical therapy, cardiac rehabilitation, or nutritional service)
• Supports the utilization review program by maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers
• Communicates closely with third party payors to ensure all pertinent clinical information is provided to secure an authorization; appropriately documents information regarding the authorization number and the approved length of stay on the Case Manager Software
• Advocates for patient/family needs in a respectful, non-judgmental, and confidential manner
• Serves as a resource to physicians for clinical management and financial issues; assists the providers with promoting efficiencies in the care delivery system and reducing/ eliminating barriers to efficient/effective service
• Reviews patient cases for potential problems with OIG Workplan Audits and compliance issues; reports problems and makes recommendation to appropriate departments
• Appropriately refers cases to manager/director of care coordination, CAO, or medical director when intensity of service or severity of illness is not present and is unable to resolved
• Educates physicians, patients, and staff with regards to payors, financial issues, documentation, and potential compliance issues
• Investigates and responds to billing concerns from Business Office, Health Information Management, Admitting, and other sources; resolves financial and billing problems, such as appropriate patient status, correct payor source, denials, appeals, and system issues

Job description

UofL Health in Louisville, KY is seeking a Utilization Review RN to support utilization management by assessing medical necessity for admission and continued stay, screening patients per guidelines, and coordinating with physicians and case managers to secure payor approvals.

The role requires documenting in Case Management Software, identifying delays, promoting efficient resource use, and educating clinicians about payer rules, with a commitment to patient-centered care and compliance with UM