Utilization Management Rn Reviewer Prn

• Demonstrates strong critical thinking and problem-solving skills.
• Has utilization review experience.
• Is an excellent communicator.
• Has three to five years of experience working in a hospital.

Responsibilities:

• Recommends resource utilization.
• Attend all staff meeting when scheduled to work.
• Other duties as assigned.
• Utilizes analytical ability required to gather data. Uses clinical judgment to apply predetermined criteria or uses independent clinical judgment when no predetermined criteria exists to identify problems, facilitate resolution, recommend corrective action, and report results effectively.
• Makes recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.
• Completes Utilization Management for assigned patients with a minimum of 25-30 reviews per day.
• Follows department guidelines on escalation processes and refer cases appropriately to the internal or external PA.
• Documents appropriately in UM notes to provide evidence that the UR process for the case was followed.
• Applies medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.
• Maintains professional work standards including confidentiality, ethical principles, and professional work habits.
• Achieves a minimum of 85% on IRR quarterly.
• Uses independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement.
• Prioritizes and organizes work to meet changing priorities.
• Maintains and supports collaborative relationships with TCC's, Physicians and the multidisciplinary team.

Education:

• Bachelor of Science in Nursing preferred.
• Graduate of an accredited school of nursing with licensure as a Registered Nurse (RN) in the State.

Certifications:

• Current valid license as a Registered Nurse (RN).
• Basic Life Support (BLS) through American Heart Association (AHA).
• Case Management Certification (CCM) preferred within first year of eligibility.

Work Experience:

• Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution.
• Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures, with experience in assigned specialty.
• Demonstrated competence in all areas identified in the Competencies, Dimensions, Problem solving, and Information Management sections Participates in departmental cost containment; cognizant of reimbursement denials and effect on cost of care.
• Knowledge of and ability to use multiple Hospital information systems and Department's software; report and follow-up on software problems resulting in delay in work flow.
• Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings; capable of providing in-service education to health care providers in regard to this topic.
• Prior Utilization Management experience is preferred.
• Proficient with Microsoft Office.
• Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes.
• Awareness of licensing and accreditation standards.
• Must possess advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.
• Basic knowledge of medical records coding standards.
• Requires three years equivalent full-time clinical experience as a Registered Nurse.
• Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets.
• Ability to use copier, fax machine and personal computer and knowledge of Microsoft Office.

Physical Requirements:

• Requires constant attention to detail, reading of medical records, and meeting deadlines.
• Works in an environment where there is some discomfort due to dust, noise, temperature.
• Requires walking, sitting, and/or standing for long periods of time.

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment.