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Utilization Review Nurse

Company: Memorial Health
Location: Springfield
Posted on: February 16, 2020

Job Description:

Performs clinical review of patient records to evaluate the utilization of acute care services. Communicates to third party payors to support the medical necessity of the hospital admission for services reimbursement. Ensures the patient care team is aware of general length of stay requirements for all patients. Facilitates physician documentation through concurrent interaction with physicians to support reimbursement and clinical severity is captured for the service rendered to patients receiving hospital care. Provides clinical knowledge and data collection for quality improvement initiatives. Optimizes reimbursement for acute care services.


  • Associates Degree in Nursing. Bachelor's Degree in Nursing preferred.
  • Evidence of continuing professional development.
  • Current RN licensure in the State of Illinois required. Experience:
    • Minimum of 3- 5 years of recent acute care and/or home health nursing or case management experience required. Previous utilization review experience strongly preferred. Other Knowledge/Skills/Abilities:
      • Understanding of healthcare reimbursement mechanisms preferred.
      • Strong oral and written communication skills.
      • Demonstrated adaptability to changes in health care environment with proactive problem solving attitudes
      • Understanding of the principles of performance improvement, team collaboration, and conflict resolution.

        Utilization Review and Management:
        • Conducts and coordinates admission, concurrent and retrospective chart reviews of all patients in a hospital bed for appropriateness of admission, level of care, and determination of length of stay based on accepted criteria. Refers account to physician advisor when case fails to meet criteria for level of care determination.
        • Discusses information with physician advisor on cases requiring level of care, follow up, or stay requirements.
        • Verifies physician orders in medical record in compliance with Medicare, Medicaid and other payer guidelines for determining level of care. Assures medical documentation reflects the illness severity & acuity of patients
        • Documents level of care changes per policy and regulatory requirements in all identified systems.
        • Communicates clinical information to external review agencies/third party payers within agreed timeframes.
        • Educates patients/families on observation/outpatient level of care and obtains written signature on required Medicare and Illinois observation/outpatient informational notice.
        • Educates patients/families on Medicare Important Message for hospital coverage and discharge appeal rights, obtains signature on notice, and facilitates appeal process when requested by patient or appropriate others.
        • Monitors patient length of stay and collaborates with physicians and multidisciplinary team to ensure resource utilization remains within covered benefit entitlements, and are appropriate for patients' overall needs.
        • Educates patients/families and healthcare providers regarding utilization issues and discharge options. Utilizes clinical skills to obtain authorization/certification of discharge plan by third party payers when necessary.
        • Serves as a resource to patients and medical staff regarding issues related to inpatient care & reimbursement.
        • Participates in care conferences. Participates in departmental on-call and weekend coverage schedule.
        • Follows up to verify approval of hospital stay for discharged patients with outstanding certification.
        • Reviews all medical necessity denials or non-certified days received for potential appeal, initiates/facilitates peer to peer appeals, completes documentation on appeal outcome with applicable recommendations.
        • Provides oversight and serves as a resource to Utilization Management Specialist.
        • Identifies problems and/or opportunities for improvement in clinical outcomes, delay in service, utilization of resources, and concurrent data collection for quality improvement initiatives.
        • Participates in ongoing education regarding regulatory (e.g. OIG, Medicare, JCAHO) and payer requirements for clinical documentation aspects of utilization management, compliance, and reimbursement optimization. Utilization Review and Management Emergency Department:
          • Reviews all patient records in the emergency department requested for bed placement for appropriateness of admission, appropriate level of care, and determine appropriate length of stay based on established criteria.
          • Review prospectively all scheduled surgeries and admissions for appropriate level of care, identifies Inpatient only procedures, resolve status related issues prior to scheduled procedure.
          • Collaborates with Patient Flow Team to provide guidance for Memorial Access admissions for medical necessity of admission in level of care. Works with Social Services for patients released from Emergency Dept.
          • Performs other related work as required or requested.

Keywords: Memorial Health, Springfield , Utilization Review Nurse, Healthcare , Springfield, Illinois

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