UTILIZATION REVIEW NURSE - CASE MANAGEMENT

Status:  Full Time

Shift:     M-F 7a-3:30p with alternating holiday coverage

Exempt: No 

Other information:

A. EXPERIENCE, KNOWLEDGE, AND SKILL

1. Previous Experience Required

a. At least one year of work experience in the hospital or insurance industry.

b. Utilization Review experience preferred.

2. Specialized or Technical Education Requirements

a. Licensed Practical Nurse currently licensed to practice in the State of Louisiana required

b. Knowledge of Prospective Payment System, DRG’s, preferred.

c. Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations.

3. Manual or Physical Skills

a. Basic Computer skills preferred.

4. Physical Effort Required

Strength: Sedentary

Push: occasionally

Pull: occasionally

Carry: occasionally

Lift: occasionally

Sit: frequently

Stand: frequently

Walk: frequently

Responsibilities:

Monitors and facilitates initial and continued stay requirements and expectations with payers and the hospital.

1. Provides front-end revenue cycle through a pre-certification and access to care strategy through collaboration with the ED utilization review/case management team.

2. Applies medical necessity, severity of illness/intensity of service criteria for patients seeking inpatient admission or continued stay using nationally recognized clinical guidelines.

3. Performs admission reviews to ensure appropriate utilization of resources and level of care determination.

4. Educates members of the patient’s healthcare team on the appropriate access to and use of various levels of care.

5. Promote use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.

6. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44).

7. Promote medical documentation that accurately reflects intensity of services, quality and safety indicators and patient’s need to continuing stay.

8. Pro-actively participate as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient’s preference, reason for admission, and availability of resources.

9. Consults with physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.

10. Communicates clinical review information to all third-party utilization review companies as per established policies and procedures to ensure continued benefit coverage for patients.

11. Performs needed concurrent and retro reviews and obtains authorizations.

12. Ensures consistent data capture to identify trends/problems related to delivery of care delays and potentially avoidable days.

13. Escalates appropriate cases to departmental leadership or physician advisor for additional support and guidance.

14. Supports the revenue cycle team by addressing denials related to medical necessity.

15. Manages Work Queues as assigned for Retro reviews, claim edits, and any other assigned correspondence with the business office.

Is an active member of the case management department and the North Oaks team

1. Fosters positive internal and external customer relations.

2. Participates in performance improvement activities as needed. Which include regular UR team meetings and may be asked to provide case reviews for internal process improvement initiatives.

3. Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.

4. Provides orientation and mentoring to new staff.

5. Follows North Oaks Health System’s Compliance Programs and federal and state regulatory guidelines.

6. Other duties as deemed necessary and appropriate.