Utilization Review RNNH-United States-Dover Apply View Saved Jobs Job ID 3156925 Date posted 05/22/2021
At Wentworth-Douglass, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives. We invite you to explore opportunities, cultivate community wellness and professional growth.
1.Evaluates the provision of care and the appropriate utilization of resources.
a.Reviews medical records for appropriateness of admission &/or continued stay using established criteria.
b.Communicates utilization issues to the appropriate individuals.
c.Serves as a resource to personnel in Patient Registration and Pre-Admission Services, & other staff as appropriate, regarding determination/ classification of the patient's admission status.
d.Discusses cases with the attending physicians; exploring strategies to optimize resource consumption.
e.Implements strategies to reduce lengths of stay when appropriate.
f.Participates in multidisciplinary discharge planning rounds.
g.Communicates with external case managers as appropriate.
h.Communicates/ collaborates with all members of the health care team, including the patient, payers, & administrators, regarding the patient's needs, plan, & response.
i.Actively conduct real time follow up on concurrent denials and pursue providing needed information to third party payors to authorize payment.
2.Demonstrates professionalism with managed care entities and processes.
.Keeps informed of changes in contractual relationships for all payer systems.
a.Provides requested information regarding patient care and services to external review and regulatory agencies.
b.Coordinates/ Performs all follow-up activities related to Medicare, other third-party payers, and hospital-negotiated contracts.
c.Communicates to patients, MDs, and other appropriate personnel changes in review findings resulting in level of care changes or findings consistent with termination/ denial of benefits.
d.Collaborates with managers & staff in the Patient Registration, Patient Accounts, and Medical Information Departments on issues of continued stay, denials, and related activities.
e.Assists medical staff in responding to appeals.
f.Provides information/ education to patients, family members, &/or patient representatives regarding the appeals process upon receipt of Medicare termination of benefits letters or commercial denial letters.
g.Informs CFO/VP of Finance and/or other management team members of situations which require notification or administrative action.
h.Assists medical record coders in clarification of medical clinical documentation issues related to DRG assignment.
3.Demonstrates excellence in leadership skills and professional performance .
.Maintains close communication with directors regarding utilization, quality of care, risk, and infection control issues.
a.Facilitates/ participates in ad hoc patient/ family conferences designed to gather information & resolve issues applicable to Utilization Review functions.
b.Participates in departmental and hospital committees, ad hoc committees, task forces and work groups.
c.Educates health team colleagues about utilization review, including the role of the case manager and the needs of the utilization reviewed population.
d.Participates in educational programs as requested &/or as appropriate.
4.Collects data pertinent to care management, utilization management, and performance improvement.
.Collects data related to clinical pathway variances.
a.Reports adverse drug reactions appropriately.
b.Reports issues related to infection control/ surveillance.
c.Collects data related to readmission's, avoidable days, attribution delays.
d.Tracks & trends over/ under utilization of resources through use of computerized database.
e.Reports data findings & any noted trends at UM Committee and to other appropriate individuals/ committees.
Experience Minimum Required
• 3-5 years of acute hospital experience.
• One year in specialty area or at least one year as Nurse Manager or at least one year in a Utilization Review or Quality Assurance position.
• 2+ years in a Utilization Review or Quality Assurance position.
Education Minimum Required
• Associates in Nursing
• Knowledge of Interqual and Milliman
Special Skills Minimum Required
• Strong clinical assessment skills and knowledge of medical standards of care.
• Knowledge of third party payer systems and levels of care.
• Extensive experience in dealing with medical staffs and medical staff committees.
• Ability to interrelate with physicians, nurses and other hospital personnel.
• Knowledge of government, voluntary and regulatory standards, requirements and guidelines for U.R. and Q.A.
•Knowledge of principles related to release of information and maintenance of confidentiality of data.
• Oral and written communication skills.
• Knowledge of basic infection control practice.
• Special Skills Preferred/Desired
• Applicable certification preferred
Licensure and/or Certifications Required
· The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)