Utilization Review Nurse
Position Summary:
The major function of the Utilization Review Nurse is to collect medical information regarding inpatient admissions and outpatient procedures/services. Information is used to determine medical necessity of the admission/procedure/service, determine length of stay, and determine the appropriateness of the level of service.
Steerage will be made to network providers and medical necessity will be determined for lower-level care.
The Utilization Review Nurse is responsible for referring cases that could benefit from discharge planning, transitional case management, personal care management or other continuum programs in accordance with individual health plan provisions.
Position Responsibilities:
- Answer incoming phone calls, review and enter clinical from EMRs and faxes promptly.
- Review assigned computer files for each reported inpatient admission and select outpatient procedures/services.
- Contact attending/ordering physician’s office or hospital utilization review to gather relevant medical information based on available criteria to include but not limited to: patient’s presenting symptoms, diagnosis, treatment, office or progress notes, labs/test results and/or estimated length of stay.
- Document all calls or contacts made, and information collected in patient’s computer file for the admission or requested service(s).
- Certify according to criteria if medical necessity is determined. Request physician or pharmacist review if questioning medical necessity.
- Follow each certified admission on the day prior to discharge for concurrent review, either closing file or contacting medical resource for reason for extended stay.
- Screen patient file and refer per clinical documentation and guidelines to the appropriate care management program: Case Management for complex needs, Transitional care for discharge planning or Personal Care Management for chronic disease coaching or prenatal program participation for education and nursing support.
- Keep contact informed about potential noncertification. Explain expedited and standard appeals processes.
- Document and report caller complaints and quality of care issues.
- Facilitate discharge planning by providing steerage to network providers.
- Any special projects or duties as may be assigned by the Manager of Utilization Review.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Position Qualifications:
Required
- Registered Nurse with active and unrestricted North Carolina nursing license
- 3 years clinical experience/or equivalent professional experience (acute care medical surgical or critical care experience preferred)
Skills, Knowledge and Abilities
- Excellent oral and written communication skills
- Exceptional customer service, and interpersonal skills
- Effective problem-solving and influencing skills
- Strong organizational, self-motivation, and decision-making skills
- Basic Computer Skills
- Ability to manage multiple priorities in a fast-paced environment
- Ability to work independently and collaboratively, as needed
Key Competencies:
- Service orientation
- Integrity
- Ethical practice and confidentiality
MedCost provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
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