RN Utilization Review, Frazier Rehab Institute

University Medical Center; Louisville (KY); On-site; USD 65,000 - 85,000; Full time

Job summary

University Medical Center is seeking a Utilization Review RN to support UM Care Management and Utilization Management processes. The role involves evaluating medical necessity for admissions and continued stays, screening against payer guidelines, and coordinating with physicians and case managers to ensure appropriate level of care.

The RN will conduct admission and concurrent reviews, document findings, and assist with billing and compliance issues in a fast-paced hospital setting in

Responsibilities

• Promotes utilization review by verifying medical necessity for admission, continued stay and discharge.
• Review concurrent cases and identify process delays to ensure appropriate resource use.
• Communicate with payors to obtain authorizations and document authorization details in the Case Manager Software.
• Educate physicians, patients, and staff on payor policies, documentation and compliance issues.
• Resolve billing problems related to patient status, payor source, denials and appeals.

Job description

Primary Location

Frazier Rehab Institute - UMC
Address: 220 Abraham Flexner Way Louisville, KY 40202

Job Description Summary

UofL Health is a fully integrated regional academic health system with five hospitals, four medical centers, nearly 200 physician practice locations, more than 700 providers, the Frazier Rehab Institute and Brown Cancer Center.

With more than 12,000 team members-physicians, surgeons, nurses, pharmacists and other highly skilled health care professionals-UofL Health is focused on one mission: delivering patient-centered care to each and every patient each and every day.

Job Description

Position Summary and Purpose

The Utilization Review RN performs activities which support the Utilization Management functions. They are responsible for the delivery of the Utilization Management process including but not limited to making clinical recommendations regarding medical necessity for admission and continues stay, screens patients for client specific guidelines regarding insurance, Medicare and/or Medicaid guidelines, send payor specific Notice of Admission and continued stay reviews. "Performs utilization review activities under established criteria, policies, and UM leadership oversight. The employee communicates with physician and case managers regarding payor approval/denial of admission and continue stay review. They process payor denials and retro reviews, promote optimal health care outcomes in accordance with the policies, procedures, applicable laws and contracts, philosophy, mission and values of UofL Health, assumes responsibility and accountability for the appropriate utilization of facilities and services and serves as a resource to physicians. The employee conducts admission and concurrent reviews including observation and inpatients, identifies patients who do not meet criteria and takes action to ensure patients are cared for in the most appropriate level of care; coordinates care in conjunction with other members of the interdisciplinary healthcare team to provide and facilitate optimal health and financial accountability. This employee utilizes the nursing process (assess, plan, implement and evaluate) and management process (plan, organize, direct and control) to provide a framework for decision-making; maintains confidentiality of information; actively supports organizational goals and objectives by providing needed information to divisions and departments. Participates in ongoing UM competency validation and regulatory education.

Essential Functions

• 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

Other Functions

• Develops a cooperative, assistive relationship with third-party reviewers, working to facilitate timely, positive responses for patient accounts
• Attends Monthly Departmental Staff