RN Utilization Review: Optimize Care & Approvals

uoflhealth; Louisville (KY); Presencial; USD 70.000 - 95.000; Jornada completa

Descripción de la vacante

UofL Health is seeking an Utilization Review RN to support the Utilization Management process, including making clinical recommendations on medical necessity for admission and continued stay. The role involves screening for guidelines, communicating with physicians and payors, and documenting reviews across case management software.

The position requires collaboration with interdisciplinary teams to ensure appropriate resources, compliance with policies, and optimal patient outcomes within a

Responsabilidades

• 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
• 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

Descripción del empleo

UofL Health is seeking an Utilization Review RN to support the Utilization Management process, including making clinical recommendations on medical necessity for admission and continued stay. The role involves screening for guidelines, communicating with physicians and payors, and documenting reviews across case management software.

The position requires collaboration with interdisciplinary teams to ensure appropriate resources, compliance with policies, and optimal patient outcomes within a