Job Summary: The Utilization Review Nurse performs Utilization Review on all patients to ensure appropriate resource utilization, authorization of hospitalization and tracking of avoidable days. Relies on education, some experience and judgment to accomplish job. Works under general supervision. Creativity and some latitude is expected to complete responsibilities.
Partnership and Collaboration:
a. A working knowledge of Managed Care Contracts, third party payor criteria and InterQual have been demonstrated as evidenced by annual competency check list.
b. Documentation of all utilization review information is validated and documented within the timeframe outlined in the department metric reports.
c. Positive, competent and respectful interaction with patients, families, caregivers, staff, co-workers, physicians, and community agencies is given at all times as evidenced by no written or verbal complaints.
c. The Business Office is immediately notified when category changes occur to ensure the appropriate authorizations for the services rendered is secured.
d. Physicians are notified of need for additional documentation or adjustments to treatment plan to promote continuum of care as evidenced by documentation and no denials.
e. Confidentiality is maintained at all times when dealing with patients, staff or physician issues as evidenced by no verbal or written complaints.
Evaluation and Analysis:
a. Patient cases are reviewed for medical necessity and intensity service/severity of illness to ensure patient is admitted to the appropriate status and authorizations for services provided are validated within the timeframe outlined in UM Department SOP and/or Payor Plan Guidelines.
b. Communicates accurate information with payor and physician to ensure coverage for services/care provided.
c. Clinical documentation is reviewed to ensure that services are being provided appropriately, and documentation meets agency and regulatory requirements.
d. Current treatment plans are reviewed daily to evaluate appropriateness of services and progress toward treatment goals as evidenced by documentation and no denials.
Quality:
a. Documentation of interventions are accurately transcribed within the timeframe outlined in UM Department SOP in the encounter-based notes as evidenced in monthly productivity and quality audits reports.
b. Medical records are submitted based on plan requirements, the receipt of the required medical records is validated, and all documentation to support the authorizations for services rendered was secured as evidenced by lack of administrative/medical necessity denials issued at the point of service.
c. Available notes for review are clear, concise, and contain evidence of action taken as evidenced in monthly productivity and quality audits reports.
d. All potential denials are reviewed followed by appropriate intervention as evidenced by documentation.
e. Prompt notification of UM Manager or Director of possible quality or physician issues as evidenced by direct observation.
Other Duties As Assigned:
a. Performs other duties as assigned or requested.
Experience: 3 years acute care LPN experience
Education: Graduate from Accredited LPN Program
Special Skills: Excellent communication and organizational skills.
Licensure: Current Louisiana or Mississippi License as an LPN