Nurse Utilization RN

Salary Range

$44.64 - $71.24
Overview

Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members.

 

Full Time Employees of Confluence Health receive a wide range of benefits in addition to compensation.

• Medical, Dental & Vision Insurance
• Flexible Spending Accounts & Health Saving Accounts
• Paid Time Off
• Generous Retirement Plans
• Life Insurance
• Long-Term Disability
• Gym Membership Discount
• Tuition Reimbursement
• Employee Assistance Program
• Adoption Assistance
• Shift Differential

For more information on our Benefits & Perks, click here!

Summary

Performs utilization review in accordance with all state mandated regulations. Maintains compliance with regulation changes affecting utilization management. Reviews patients records and evaluates patient progress. Performs continuing review on medical records and identification and need of on-going hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests. Conducts reviews and validates physician's orders, reports progress and unusual occurrences on patients. Ensures appropriate and cost-effective healthcare services to patients. Documents review information in computer. Monitors all Outpatient in a Bed & Inpatient surgeries for correct status. Reviews the insurance prior authorizations for correct status. Uses the Medicare Inpatient Only list of surgery CPT codes for correct status/class to ensure reimbursement for surgeries. Reviews all denials from insurance companies for correct status/class. Pursues peer to peer discussions between our hospitalists and insurance MD, reconsideration, appeal, administrative rate, or change in status/class.

 

Position Reports To: Director of Utilization Management

Essential Functions

1. Prepares and organizes initial and continued stay utilization reviews.

   • Complete admission review per MCG guidelines.

   • Coordinates provider certification of Medicare inpatient hospital stays as required in the Medicare Benefit Manual, Final Rule etc.

   • Utilizes clinical information located in the patient record to support patient status decisions and recommendations. Documents this information in MCG.

2. Collaborates with other departments regarding review results.

   • Issues MOON letters to patients per Medicare guidelines to notify them of their Observation status and billing of Medicare Part B.

   • Communicates to care management staff when payers deny the patient stay.

3. Complies with Medicare and other regulations for second level review by the UR Committee, notification of patient, physician, and hospital of particular status changes.

   • Follows the A/B Rebill flow maps as indicated.

   • Ensures written notification to the patient, physician, and hospital when the final outcome of a second level review is A/B Rebill.

   • Notifies patient accounts to hold submission of a bill when a case has been sent for second level review and the patient has been discharged.

   • Notifies patient accounts to submit the bill when the results of the second level review is known, along with the results.

   • Participates in tracking and monitoring second level reviews as directed.

4. Adheres to Workflows and Process Maps specific to UM functions.

   • Follows process flow maps and established workflows. Participates in standard work.

   • Assist in identifying processes and procedure improvements to positively affect work flows.

5. Issues Notices of Non-coverage according to policy and procedure.

6. Complies with the various private contracts regarding review, pre-authorization, phone calls, deliver non-coverage letters as required and/or appeal denials.

   • Provides Clinical information to payers as requested and per contract.

   • Facilitates concurrent Peer to Peer discussions between providers when a payer denies all or part of a hospital stay when the denial occurs prior to discharge.

   • Communicates the results of Peer to Peer discussions, if known, with business office and patient accounts.

   • Tracks all discussions with payers in the appropriate billing system, according to facility.

7. Assist with the process following an appeal of discharge, as outlined in the Important Message from Medicare.

   • Provide requested clinical information to the QIO following a patient’s appeal of the discharge decision.

   • Deliver a HINN-12 notification following a decision from the QIO to uphold a decision to discharge, according to procedure.

8. Performs other duties as assigned.

Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.

Qualifications

Required:

• Associate's Degree in Nursing.

• Three (3) years experience in an acute care setting as a Health Care Professional with demonstrated expertise in specific clinical area.
• Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499).
• Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking. Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis.
• Excellent verbal and written communication skills.
• Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
• Must possess basic computer skills related to Windows navigation, email communication.

Desired:

• Bachelor's Degree in Nursing (BSN) or related field.

• Accreditation in ACMA.

Physical/Sensory Demands

O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday.F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday.C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday.
Physical/Sensory Demands For This Position:

• Walking - O
• Sitting/Standing - C
• Reaching: Shoulder Height - O
• Reaching: Above shoulder height - O
• Reaching: Below shoulder height - O
• Climbing - O
• Pulling/Pushing: 25 pounds or less - O
• Pulling/Pushing: 25 pounds to 50 pounds - O
• Pulling/Pushing: Over 50 pounds - O
• Lifting: 25 pounds or less - O
• Lifting: 25 pounds to 50 pounds - O
• Lifting: Over 50 pounds - O
• Carrying: 25 pounds or less - O
• Carrying: 25 pounds to 50 pounds - O
• Carrying: Over 50 pounds - O
• Crawling/Kneeling - O
• Bending/Stooping/Crouching - F
• Twisting/Turning - O
• Repetitive Movement - C

Working Conditions:  

• Work is performed in a hybrid setting with remote work as well as in an office environment. Involves frequent contact with staff, leadership and practitioners. Work may be stressful at times.

Job Classification:

• FLSA: Non-Exempt
• Hourly/Salary: Hourly

Physical Exposures For This Position:

• Unprotected Heights - No
• Heat - No
• Cold - No
• Mechanical Hazards - No
• Hazardous Substances - No
• Blood Borne Pathogens Exposure Potential - No
• Lighting - Yes
• Noise - Yes
• Ionizing/Non-Ionizing Radiation – No
• Infectious Diseases - No