Performs admission and continued stay utilization reviews and discharge screening to assure the medical necessity of hospital admission, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services. Coordinates care transitions from inpatient to the next level of care. Collaborates with attending physicians, advanced practice providers, and/or Department Medical Directors concerning status and/or medical necessity issues. Follows departmental policy to escalate cases to second level review when criteria is in question. The UR RN consistently interacts with physicians, nurses, revenue cycle services, other patient caregivers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patient and the clinical information utilized in profiling and reporting outcomes is completed. Monitors and evaluates care to ensure care is medically necessary, provided in the appropriate setting, and generated according to governmental and regulatory agency standards. Talent Pool: Nursing |
| Proactively conducts initial case review within 24-48 hours of admission for all inpatients utilizing criteria accepted by Cone Health as defined in the departmental Utilization Management Plan. Subsequent reviews will be conducted as long as the patient remains in the hospital following required government rules and regulations and/or third party payor rules and regulations. Observation cases will be reviewed daily to assess the need for continued observation, conversion to inpatient status, or discharge. All reviews will be completed and documented in EPIC. Carriers requesting clinical information will be sent secured via payor access and recorded in EPIC to include date and time of transmission. Communicates all review outcomes to all relevant parties including medical staff and hospital staff. 30% Through the medical record review, evaluates for discharge planning needs of patients and makes appropriate and timely referrals to the transition of care team in order to ensure a timely discharge and provide appropriate linkage with post discharge care providers. Collaborates with the care team in developing and expanding the plan of care to encompass multidisciplinary patient care needs. 10% Routinely refers appropriate issues/cases to the Department?s Physician Advisor in a timely manner. Communicates effectively with peers to assure that patient needs are met including handoffs and staff covering care. Serves as a liaison between physician, payor, and patient regarding non-coverage of benefits and/or denials. 20% Provides oversight of utilization of resources. Accurately identifies issues surrounding the appropriate utilization of resources and provides follow up corrective action in a timely manner in collaboration with appropriate healthcare team members. Provides immediate, on-going education of healthcare team members on such issues as payer requirements, denials, avoidable delays/variances, regulatory agency regulations, compliance, post-acute provider referral processes and other appropriate alternative care options. Monitors authorization with patient status to ensure accuracy. Consistently and accurately documents and completes code 44 process and avoidable days prior to the patients discharge. 20% Provides documentation of UR processes. Supports other department and healthcare team members in providing appropriate services and effective care by supplying comprehensive documentation in Cone Health electronic systems as required by policy. Coordinates with the denials team in the appeals process working closely with physicians and service areas. Maintains appropriate information on file to minimize the denial rate. Assists in recording denial updates, overturned days while monitoring and reporting denial trends that are noted. Monitors for readmissions and reports possibilities for readmission and current readmissions to the assigned transition of care nurse. 20% |
| EDUCATION: |
| Required: Bachelor's degree in nursing or healthcare related field Preferred: Bachelor's degree in nursing (BSN) Master's degree in business, nursing or healthcare related field |
| EXPERIENCE: |
| Required: At least three (3) years acute nursing experience. Working knowledge of computers and basic software applications including Microsoft Word, Excel, PowerPoint, etc. Preferred: Three (3) or more years in Utilization Review utilizing national evidence based clinical support software. Working understanding and requirements for health plan utilization management. |
| LICENSURE/CERTIFICATION/REGISTRY/LISTING: |
| Required: RN | Registered Nurse licensed in North Carolina or a Compact state Preferred: |
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