RN Utilization Review - 6027

Kingman Regional Medical Center is hiring an RN for Utilization Review. Position Code: RN-6027

Position Title: Utilization Review Nurse

Department: Case Management Safety Sensitive: Yes

Reports to: Director of Case Management

Exempt Status: No

Position Purpose

All KHI employees are expected to perform their tasks in support of KHI’s vision of providing the region’s best clinical care and patient service in an environment that fosters respect for others and pride in performance.

Key Responsibilities

• The Utilization Review Nurse conducts and coordinates medical necessity reviews for Medicare, Medicaid, self-pay and other insured patients, upon admission and throughout the inpatient stay.
• Verifies physician orders in the medical record per Medicare and payer guidelines to determine level of care; ensures documentation reflects the severity of illness and acuity.
• Communicates with KHI medical staff to reconcile and clarify admit orders and medical documentation to ensure appropriate reimbursement for services rendered.
• Consults with Physician Advisor as needed to determine medical necessity and referrals for cases not meeting criteria per the Utilization Management Plan.
• Works with Case Managers and Insurance Specialists to provide appropriate clinical information to payers within required timeframes per KHI policies.
• Enters and maintains information related to the utilization review process in MCG and other data systems; documents all activities to support medical necessity determinations.
• Collaborates with the healthcare team, business office and payers to ensure high-quality, cost-effective patient care.
• Identifies issues and trends related to medical necessity denials with the Denial Manager and RAC team; participates in the denials management process.
• Serves as a resource to Case Management staff, providing education on clinical guidelines, utilization review and payer regulations.
• Establishes a communications system for days off.

Review Process

• Reviews medical records concurrently and retrospectively as needed to assess case management against predetermined criteria.
• Evaluates information against nationally recognized criteria to determine necessity for admission, continued stay, appropriateness of service, and level of care.
• Collaborates with physicians to determine appropriate inpatient versus observation status and ensure documentation.
• Performs Code 44 when needed.

Utilization

• Determines which cases require medical staff review intervention and/or UR management intervention.
• Considers factors such as appropriateness and quality during Case Management.
• Communicates with the attending physician regarding expected length of stay and Medicare guidelines.
• Collaborates with Case Managers and Insurance Specialists to ensure proper documentation and awareness of potential denials; clarifies documentation in the EMR as needed.
• Educates Case Managers, Social Workers, and Physicians on CMS guidelines and documentation requirements.

Quality Of Care

Protects patient rights and confidentiality during the case management process.

Compliance

• Participates in committees, performance improvement activities, mandatory in-services, and continuing education.
• Maintains compliance with hospital policies, safety, environmental and infection control guidelines.

Education & Licensure

Education: Graduate from an accredited school of nursing

Licensure/Certification: Current, valid Arizona or compact state RN license

Qualifications

• Minimum of three years clinical RN experience, preferably in hospital medical-surgical or critical care.
• At least one year utilization review experience or two years case management experience as an RN.
• Strong clinical skills and ability to recognize quality issues.
• Knowledge of criteria used to make medical necessity determinations; Milliman or InterQual experience preferred.
• Strong interpersonal, organizational and communication skills.
• Problem-solving skills with ability to analyze complex situations and implement actions.
• Ability to work with diverse populations and adapt to change.
• Good assessment skills and knowledge of factors affecting discharge status.

Preferences

• Education: BSN or MSN
• Licensure/Certification: CCM or ACM

Workplace Requirements

• Blood Borne Disease Exposure Category II; other hazards may include volatile/violent patients or family members.
• Ability to handle multiple priorities; operate technical equipment; sit for 3-5 hours, stand for 3-5 hours, and walk for 3-5 hours per day.