May be eligible for $3,000 sign on incentive

May be eligible for relocation assistance

May be eligible for tuition loan reimbursement

Under the direction of department leadership, the Utilization Review/ Management RN. This position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, and coordination to decrease avoidable denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments.

Essential Job Functions

•Supports and models behaviors consistent with Billings

Clinic’s mission, vision, values, code of business conduct and service

expectations. Meets all mandatory organizational and departmental requirements.

•Maintains

competency in all organizational, departmental, and outside agency

requirements.

•The

responsibilities of the UR case manager are listed below, in order of priority

and intended to ensure effective prioritization of tasks.

•Priority

1: Reviews New Admissions, Observation and Outpatient Cases

•Prioritize

reviews of all OBS and bedded Outpatients

•Communicate

with attending physician to discuss case and obtain information not documented

in record, when OBS cases do not meet payer criteria or OBS = 24 hours

•Communicate

with attending physician for OBS patients meeting medical necessity for

inpatient level of care to obtain inpatient order

•Communicate

with Case Manager to understand discharge plan and barriers to discharge on OBS

and Outpatient in a Bed patients

•Participate

in daily OBS call and communicate why patient is here, what we need from the

team to get the patient to the next level of care, and expected discharge plan

•Ensure

that admission review is completed on assigned units/worklist using payer MCG

or CMS 2 Midnight Rule within 24 hours of admission

•Identify

incomplete reviews from worklist

•Validate

OBS orders daily for new admissions, within 24 hours

•Ensure

order in chart coincides with the payer review, CMS 2 Midnight Rule, or payer

authorization for status and level of care

•Priority

2: Performs Utilization Review (UR) Activities

•Completes

concurrent Level of Care (LOC) & status reviews utilizing payer criteria to

assure all days of hospitalization are covered/certified or meet CMS 2 Midnight

Rule (as appropriate) at minimum of every 3 days or more frequently based on

payer requirements

•Reviews

observation patients at a minimum twice a day. Communicates with attending on

medical plan and Case Manager on discharge plan to expedite progression to next

level of care or discharge

•Discusses

case with attending when payer authorization does not match status or level of

care.

•Obtains

information not documented in the EMR and requests documentation of medical

necessity to support appropriate status (IP, OP, OBS) and level of care

(Med-surg, SDU, ICU, etc.)

•If

attending is unable to provide additional clinical information supporting

status or LOC, escalate case to the physician advisor for second level review

as early as possible and before leaving for the day

•Communicates

to Case Manager any discrepancies on status or level of care based on medical

necessity and/or payer authorization discrepancies

•Communicates

to Case Manager on current outliers, potential outliers, and denials

•Identifies

reviews that need to be completed on assigned floors and follows all assigned

patients through completion and submission of Discharge Summary

•Assesses

if all days are authorized/certified by respective payers and communicate any

issues/denials to attending physician, CM, and department leadership

•Conducts

UR until all tasks are completed; indicates UM Complete in authorization and/or

certification

•Communicates

with payer UR representatives on status/level of care authorizations that do

not match MCG review

•Denotes

relevant clinical information to proactively communicate with payers for

authorizations of treatments, procedures, and Length of Stay; sends clinical

information as required by payer

•Notifies

appropriate parties of any changes in financial class including conversions,

Hospital-Issued Notices of Noncoverage (HINN), Condition Code 44, and Important

Message from Medicare (IMM).

•Follows

department procedures and policies for Condition Code44, Physician Advisor

review, and HINN processes

•Documents

Avoidable Days/Delays, per department process/procedure/policy

•Priority

3: Maintains an Active Role in Denial Prevention and Management

•Uses

payer MCG criteria and supporting documentation to justify the patient’s

medical necessity for observation, admission and/or continued stay

•Proactively

interacts with payers and proactively sends clinical reviews to prevent

inpatient denials

•Proactively

communicates with payer UM representatives on denials and coordinate peer to

peer review with payer’s medical director

•Initiates

and coordinates peer to peer reviews on all concurrent denials

•Understands

payer requirements and government regulations to ensure compliant, safe, and

cost-effective healthcare

•Priority

4: Identify Prolonged LOS patients, readmission, or complex discharge needs

patients

•Identifies

Prolonged LOS patients or complex patients/situations and communicate to the CM

and/or Social Worker as appropriate

•Priority

5: Escalation

•Refers

cases that require second level review to Physician Advisor, Manager, and

Director per department process or procedure

•Discusses

status/level of care and payment barriers with attending for resolution, if

unsuccessful, escalate to department leadership and Physician Advisor, per

department process or procedure

•Insurance

and Utilization Management

•Maintains

working knowledge of CMS requirements and readmission penalties

•Maintains

working knowledge of insurance/payer benefits

•Documentation

•Documents

accurately and in a timely manner in the Electronic Medical Record per program

guidelines

•Utilizes

standards of professional practice in all documentation and communication

consistent with organization/department policy as well as the Board of Nursing

and ethical guidelines established and universally supported by the nursing

profession

•Assures

documentation and patient information is secure and maintained in accordance

with Billings Clinic policy, HIPPA, state and federal guidelines

•Professional

Accountabilities

•Participates

in continuing education, department planning, work teams and process

improvement activities

•Maintains

current Licensure

•Adheres

to department and organizational policies addressing confidentiality, infection

control, patient rights, medical ethics, advance directives, disaster protocols

and safety

•Demonstrates

the ability to be flexible, open minded and adaptable to change

•Maintains

competency in organizational and departmental policies/processes relevant to

job performance

•Utilizes

standards of professional practice in all communication with patients, support

systems and colleagues consistent with the Board of Nursing and ethical

guidelines established and universally supported by the nursing profession

•Maintain

utilization review data, as assigned by department.

•Performs

all other duties as assigned or as needed to meet the needs of the

department/organization