RN, Onsite Utilization Review

Primary Function:  

The Inpatient Onsite Review Nurse will be responsible for the effective and sufficient support of all utilization management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.

 

Essential Duties and Responsibilities:Performs all utilization review activities according to Health Services policy and procedures.  Contacts providers as appropriate to obtain necessary information Evaluates and authorizes the medical necessity of inpatient and outpatient services as assigned by application of approved criteria and established policies and guidelines Refers cases to the Medical Director/Physician Advisor as appropriate Enters all information into the health plan?s computer documentation system ensuring complete and accurate information in a timely manner Notifies hospital and/or providers or all denials and generates denial letters when recommended by the Medical Director/Physician Advisor Evaluates each case for quality of care, documents quality issues and appropriately refers cases to the quality management coordinator Reviews selected claims and retrospective requests for certification and follow-up as necessary with the UM Manager or Medical Director Participates in education of providers regarding Health Services policies and procedures.  Identifies and refers cases to the case management or disease management department as appropriate Assists with discharge planning Maintains strong working relations with internal and external customers.  Presents all communication in a positive and professional approach Attends and actively participates in weekly staff meetings Maintains confidentiality in all aspects of operations Assists the Inpatient Manager and/or V.P. of Health Services in tasks as assigned

 

Job Related Skills:Communicates information accurately and timely to internal and external staff.  Written and oral communication is accurate and timely and at the appropriate level Ability to articulate clinical and non-clinical information to personnel of all levels of understanding Ability to communicate with team members in a positive manner Assists education of internal and external staff in operations, policies, and procedures, and regulatory standards Ability to handle multiple tasks, set priorities, and develops action items Knowledge of regulatory requirements with emphasis on Medicare Detail-oriented, excellent organizational skills, highly self-motivated and dependable Team and goal-oriented Basic knowledge of mainframe/PC systems

 

Requirements Include:Current licensure as a registered nurse in the state of Florida, or an active license in a compact state allowing the ?multi-state privilege to practice? in Florida. 2-3 years clinical experience with at least 1-2 years in utilization review preferred Managed care experience preferred Knowledge of ICD-9 and CPT coding guidelines for utilization review preferred