Utilization Review Nurse (RN)

Scope:

Seeking a RN with a minimum of 2 years of experience in working as a utilization review nurse in an acute care setting.  Must be experienced working with Epic.  Must be experienced with reviewing payor policies for medical necessity criteria regarding observation and inpatient. Preferably experienced with InterQual, but willing to train for the right candidate.  Must be able to conduct reviews on minimum of 20 cases per shift, post training and 4 week ramp up.  Client is on Pacific time must be able to work most of the shift between 8am and 4pm PST.  

Job Summary
The Utilization Review RN monitors utilization practices from preadmission to discharge to assure cost-effective utilization of resources, quality
patient care, and compliance with regulatory requirements. This role is responsible for reviewing the medical record to ensure documentation
demonstrates medical necessity according to regulatory guidelines. The Utilization Review RN will actively manage and communicate with key
members of the care team to secure accurate documentation and admission status.
Job Requirements
2 years’ progressive nursing experience in an acute care setting preferably within discharge, utilization and/or case management or equivalent
combination of education and/or experience.
Required:
*RN: Registered Nurse Licensed by Oregon State Board of Nursing
Preferred:
*Bachelor's degree in Nursing
*CCM: Certified Case Manager
*ACM: Accredited Case Manager
Additional Position Specific Requirements
Working Conditions
Essential:
* Phy-Sit comfortable position,frequent opportunity to move
* Enviro-Indoor-Comfortable area
* Hazards-Only unplanned exposure to blood, body fluids
* HIPAA-Pay-View or read only minimum for work assignment
* HIPAA-Treat-Originate, view, change nec for work assignment
* HIPAA-Ops-View or read only minimum for work assignment
Responsibilities
1 Communication. Accepts responsibility for receiving and disseminating information related to system, departmental and patient processes.
1.1 Participates in department and inter-departmental meetings. Consistently uses both camera and audio function during remote meetings as
necessary
1.2 Takes responsibility for reviewing staff meeting minutes when unable to attend scheduled meetings.
1.3 Uses email, Microsoft Teams and other forms of communication appropriately and as directed by Asante policy.
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1.3 Uses email, Microsoft Teams and other forms of communication appropriately and as directed by Asante policy.
1.4 Escalates issues to supervisor appropriately per department guidelines.
2 Data Collection. Participates in data collection activities to support departmental programs and services.
2.1 Keep accurate statistics of interventions as related to team productivity.
2.2 May need to collect and analyze surgical case data for monthly submission.
2.3 Works with team lead/supervisor to ensure accurate reporting related to team productivity and physician practice trends.
2.4 Maintains electronic accounting of cases worked by entering detailed notes correctly into EPIC.
2.5 May need to keep accurate statistics on review outcomes to identify problem areas along continuum that need addressing and to assist in
future physician contract negotiations.
3 Performance Improvement and collaboration. Monitors and reports on patient outcomes and actively works with other members of the
interdisciplinary team to facilitate improved delivery of cost-effective services.
3.1 Actively participates on interdepartmental or intradepartmental process improvement activities.
3.2 Demonstrates flexibility and willingness to adjust workload or duties in response to unexpected changes in work volume, emergencies, staffing
and scheduling.
3.3 Provides ongoing education for physicians and nursing staff in regulatory mandates as they apply to utilization management practices.
3.4 May need to identify trends and areas of opportunity for provider specific education.
3.5 May need to investigate department circumstances that create barriers to having a complete medical record pre-operatively.
4 Professional Development. Accepts responsibility for professional self-development.
4.1 Demonstrates excellence in clinical practice through proactive, self-directive behavior using creative thinking skills..
4.2 Strives to improve practice though participation in educational activities, staff meetings and unit committees.
4.3 Functions as a positive role model and recognizes and utilizes the expertise of colleagues to create a cohesive work team.
4.4 Handles issues using assertive communication skills and takes action based on constructive performance feedback seeking guidance when
appropriate.
4.5 Provides input for development of department goals and objectives and incorporates department goals and objectives in clinical practice.
4.6 Maintain current knowledge related to medical necessity such as InterQual criteria, CMS guidelines. May need to maintain knowledge of payor
policies and contract language, NCD/LCD.
4.7 Maintains a working knowledge of all government and major third party payor/hospital contractual stipulations affecting operations.
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5 Review of medical necessity. Conducts utilization review, evaluates clinical information, and communicates findings to payors within the
framework of contractual and government regulations.
5.1 Applies InterQual criteria appropriately to determine medical necessity from admission to discharge.
5.2 May need to apply InterQual in conjunction with payer specific policies, NCD/LCD to establish medical necessity for surgical services prior to
admission. Secures adequate documentation prior to service or escalates case for intervention by leadership if provider fails to provide records.
5.2 Conducts timely reviews with payors to obtain admission or continued stay authorization.
5.3 Provides feedback to patient/physician on payor determinations concerning continuing care and facilitate a physician peer to peer as necessary.
5.4 Applies evidence-based screening tools such as InterQual in conjunction with payer specific policies to establish medical necessity for surgical
services. Secures adequate documentation prior to service or escalates case for intervention by leadership if provider fails to provide records.
5.5 Reviews patient records to ensure appropriate status, compliance with clinical guidelines and policies.
5.6 Communicate with providers regarding patients that do not meet criteria or medical necessity to identify potential documentation needs or a
potential change in status.
5.7 Completes trends as applicable when patients are admitted to inpatient status without medical necessity or when patients remain hospitalized
without documented medical necessity.
5.8 Review accounts routed to specific work queues in Epic.
6 Remote Work (if applicable) – see policy 400-COPR-HR-0411
6.1 Work-station Responsibilities
6.1.1 Maintains strict HIPAA compliance with a secure workstation in a private space.
6.1.2 Has private internet connection with bandwidth necessary to complete job function.
6.1.3 Maintains confidentiality of medical records through proper use of passwords, in accordance with Asante policy.
6.2 Performance Standards to be met for eligibility for remote work and at the discretion of leadership.

1. RN with a minimum of 2 years of experience in working as a utilization review nurse in an acute care setting.  

2.Must be experienced working with Epic.  

3. Must be experienced with reviewing payor policies for medical necessity criteria regarding observation and inpatient. 

4.Preferably experienced with InterQual, but willing to train for the right candidate.  

5. Must be able to conduct reviews on minimum of 20 cases per shift, post training and 4 week ramp up.  

6. Client is on Pacific time must be able to work most of the shift between 8am and 4pm PST.  

7. Good written and verbal communication skills