Utilization Review Professional

Summary:

The Utilization Review RN, Lead is responsible for the oversight, planning, direction, and coordination of Utilization Review (UR) services of the Care Management Department under the leadership of the ACU/CM Manager. The Utilization Review RN, Lead ensures compliance with all CMS regulations. Responsibilities include staffing as UR RN, training others in Utilization Review and Utilization Management, including performance management, improvement plans, and policies.

Duties:

• Provides Utilization Review support, education, and guidance for other UR RNs, and education and direction for Social Workers, as relevant to their responsibilities.
• Leads the multidisciplinary rounds as directed by the Manager of ACU/CM.
• Reviews medical records for determination and documentation of medical necessity for inpatient and/or observation status utilizing established criteria and methods.
• Identifies issues and variations in utilization and escalates to appropriate members of the health care team. Actively supports measures that promote effective use of resources.
• Develops and coordinates discharge plans with input and involvement of the health care team.
• Incorporates priorities and decisions made by patients. Implements discharge plans in partnership with staff RNs.
• Identifies patients at risk for encountering problems post-hospitalization and collaborates with Social Services for referral to appropriate discipline team members and outside agencies to support best patient outcomes.
• Advocates for services and funding as appropriate and necessary to meet care plan goals.
• Identifies care plans and arranges for appropriate services, applying knowledge of services available in the community, while adhering to state and federal health regulations.
• Demonstrates knowledge of procedures which assure quality care and effective utilization of hospital services; applies this knowledge when coordinating discharge plans and reviewing medical records.
• Monitors the patient’s condition and responsiveness to their interventions.
• Communicates effectively and works collaboratively with patients, staff, other departments, and providers to ensure that patient needs are being met.
• Fosters professional, positive, and collegial relationships with managers, physicians, and other hospital staff members.
• Uses effective communication, problem identification, and effective conflict resolution. Assists in supporting the team in addressing difficult interactions.
• Other duties as assigned. Accepts delegated responsibilities from the Manager of ACU/CM.
• Manages and coordinates utilization management, clinical coordination, palliative care, and discharge planning for assigned patient areas.
• Collaborates with the Emergency Department (ED) physicians, staff, and social worker to determine admission level of care.
• Collaborates with the ED physician, admitting physician, and ED MSW using the guidelines set forth for potential social admissions, to best meet the needs of the patient and the organization.
• Assists Manager of ACU/CM in managing the daily/monthly budget performance, including productivity.
• Assists medical records and patient accounts with chart and charge capture review, as directed by Manager of ACU/CM.
• Leads daily multidisciplinary care rounds. Ensures safe discharge plans. May delegate leadership of the care rounds to another RNCM when necessary.
• Works collaboratively with other departments (Medical Records, Admitting, Patient Accounts, and Compliance) in the review of coding, utilization, and discharge issues.
• Participates in developing and maintaining positive relationships with post-hospitalization care organizations.
• Maintains compliance with external requirements.
• The Manager of ACU/CM may delegate the CM/UR/SW monthly schedule to the Lead CM/UR RN.
• Prioritizes patients according to intensity, need, and required follow-up. Assists the patient to identify and/or develop a support system and encourages the patient to utilize their support system.
• Collaborates with physicians, other healthcare team members including inpatient facilities, the patient’s payer, and health system administrators to facilitate care across the healthcare continuum and optimize clinical and financial outcomes. Maintains a working knowledge of payer requirements.
• Develops collaborative working relationships with insurance case managers; negotiates on behalf of patients with third parties for cost-effective, high-quality services and to maximize the efficient use of resources.
• Ensures appropriate documentation of utilization management data. Seeks out CDI (Clinical Documentation Specialist or Interventionists) reports and reviews. Updates the ACU/CM Manager. Assists with gaining physician and hospital staff buy-in to ensure payers’ requirements are met.
• Reviews clinical appeals with the UR Physician, or third-party Physician Advisor, to reverse items returned for lack of documentation or evidence supporting the admission.
• Reviews LOS greater than 5 days with hospitalists or other admitting physicians for alternative care resolutions.
• Maintains positive interdepartmental relationships.
• Serves as a role model and change agent for the team.
• Facilitates completion of the orientation process for new staff members.
• At the Manager’s request, develops and maintains an appropriate staffing plan.
• Assists with establishing and maintaining department-specific onboarding processes including departmental orientation checklists, competency evaluations, while also collaborating with Nurse Educator, preceptors, and Clinical Programs Coordinator for various educational needs.
• Performs other related duties incidental to the work described herein.