The Utilization Review (UR) RN 1 PRN uses utilization management techniques to determine the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities. Responsible for the timely regulatory compliance and facilitation of precertification and payer authorization processes when indicated. Actively participates in clinical performance improvement activities
Job Responsibilities
- Collects delay and other data for specific performance and/or outcome indicators. Assists in the collection and reporting of resource and financial indicators including acute and post-acute case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals. Collects, analyzes and addresses variances from plans of care and care paths with physicians and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning, chronic disease planning).
- Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. Ensures safe care to patients by adhering to policies, procedures and standards within budgetary specifications including time management, supply management, productivity and accuracy of practice. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency. Supports department-based goals which contribute to the success of the organization.
- Collaborates/communicates with internal and external case managers and UR RNs. Understands pre-acute and post-acute resources. Work closely with members of patients' healthcare teams to manage and coordinate all areas of patients' care. Works holistically to ensure that healthcare plans and discharge plans meet the physical, social and emotional needs of patients.
- Acts as an advocate for patients to resolve barriers to care progression. Uses utilization management techniques to determine the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities.
- Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows-up to resolve problems with payers as needed. Applies approved clinical criteria to monitor appropriateness of admissions, continued stays or post-acute setting appropriateness and documents findings based on department standards.
- Identifies at risk populations by using approved screening tools and following established reporting procedures. Monitors LOS and ancillary resource use, depending on inpatient stay or outpatient program criteria, on an ongoing basis and takes actions to achieve continuous improvement efficiencies in both areas. Refers cases and issues appropriately to resolve barriers to care progression.
- Communicates routinely with interdisciplinary healthcare team members and other appropriate parties with regard to the status of patients' care plans and progress toward treatment goals, identification of concerns and/or problems, problem solving and assisting with conflict resolution when necessary. Works with the multidisciplinary team to address/resolve system problems impeding diagnostic or treatment progress. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. Ensures that all elements critical to patients' care plans have been communicated to the patients/families and members of the healthcare team.
- Coordinate and facilitate correct identification of patient status. Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.
- Prepare succinct, written clinical case summaries that include rationale for the recommended billing status as per Utilization Management department policy.
- Assess the utilization of healthcare resources to ensure efficient and cost-effective care delivery.
- Ensure that medical services adhere to clinical guidelines and standards of care.
- Maintain accurate records of reviews, decisions, and communications regarding patient cases.
- Participate in quality improvement initiatives aimed at enhancing the efficiency and effectiveness of healthcare services.
- Ensure compliance with regulatory requirements and accreditation standards related to utilization review and documentation.
- May perform other duties as assigned.
Additional Requirements
Certification - Basic Life Support upon startLicensure - Licensed or eligible for licensure in the Commonwealth of Virginia as a Registered Nurse upon startExperience - 1 year of bedside nursing experience Education - Bachelor's Degree in Nursing
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Inova Health System
Nov 26, 2024