Utilization Review RN | PRN | Days

The RN Utilization Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources. The Utilization Manager is responsible for ensuring that care is provided at the appropriate level of care based on medical necessity. In addition, the Utilization Manager will work towards denial prevention, promote appropriate length of stay, and ensure compliance with state and federal regulatory requirements. The Utilization Manager will work with payers to support admission, level of care, length of stay, and authorizations for services provided.

• Clinical review on all assigned patients performed to document if MCG criteria met in the appropriate setting (Inpatient or Observation). Review includes completion of Important Message from Medicare and Medicare Outpatient Observation Notices as required by Medicare and Medicare Advantage Plans.
• Application of MCG SI/IS criteria to assure necessity of admission/CSR (including all adults and pediatrics). Effectively summarizes and refers cases not meeting criteria to Physician Advisor.
• Applies regulatory requirements and policy concerning observation regarding time limitations in observation, physician order for observation, physician conversion order to inpatient, and determining the appropriate diagnostic test setting for outpatient versus inpatient.
• Collaborates daily with the direct care givers (care coordination, nurses, and physicians, ancillary departments) to coordinate the patient’s length of stay, timely utilization, and appropriateness of those resources. Collaborates with care coordination in event of necessary referral cases.
• Provides documentation review to certify the admission and/or continued length of stay to the third party payers; negotiating for additional days if necessary. All documentation noted in ACM.
• Tracking of Avoidable Days in ACM by completing the necessary user defined fields of data. Uses this data to address opportunities for improvement.
• Flags cases for the Risk Manager and Quality Assurance Coordinator regarding adverse events, appropriateness of procedures, and quality of care issues.
• Enters Medicaid chart data into the eQHS computerized system to obtain appropriate authorization and approval of continued stay days. Also assures timely inputs of Medicaid retro reviews when eligibility is confirmed.
• Identifies opportunities for improvement in the hospital system processes as well as suspected problems of under or over utilization in inappropriate scheduling of services and bring attention to the Case Management Manager. Observes rules of confidentiality specific to the Case Management Department (information obtained in files, committee discussions, data security, proper disposal of QA information, etc.).
• All other duties as assigned by department.

Required education:

• Associates in Nursing

Required experience:

• 3 years of acute care nursing