Registered Nurse - Utilization Review

Work Status:

Full-time | 40 Hours per

Week Department:

Utilization Review Job Summary Responsible for reviewing the utilization of hospital resources against established criteria set by CIMRO or other external agencies. Monitors and evaluates the medical necessity, appropriateness and intensity of service requirements for admission and continued stay in the hospital to comply with government and insurance agency reimbursement policies. Provides reports and recommendations to medical and hospital staff for improved utilization of resources and to maximize reimbursement while maintaining quality care. Essential Functions

• Performs reviews of inpatient, outpatient observation, and ambulatory services medical records to determine appropriate admission level of care and/or appropriateness of a continued stay.
• Coordinates with other hospital departments including, but not limited to social services, business office, outpatient department, surgery, and all admission personnel in matters of review decisions, discharge planning, and fiscal communication.
• Coordinates closely with physicians and the Utilization Review (UR) Committee to refer cases that do not meet criteria for review and then determine the course of action when the case fails to meet admission or continued stay standards.
• Acts as hospital liaison with Medicare, Commercial Payers, and other external review agencies.
• Provides education to hospital and medical staff regarding utilization management.
• Maintains professional growth and development by keeping current on UR rules, regulations and policies.
• Compiles and analyzes data for utilization management activities and maintains logs and statistics.
• Explains financial responsibilities to the patient or responsible party when admitted to an outpatient observation level of care or any other level of care if questions arise. If UR is unable to answer these questions, then other resources will be utilized.
• Provides information to the patient or patient representative on their Hospital Discharge Appeal Rights.
• Advocates for patients and family members and acts as a liaison with insurance companies and other third parties to assist in obtaining insurance and other financial information to secure financial approval for services.
• Regular attendance at the assigned work location is an essential function of the job.