Utilization Review Nurse - Case Management * Days - 32hrs/wk.

General Summary:

The Utilization Review Nurse performs clinical reviews using accepted screening criteria for medical necessity. This review includes appropriateness of health care services, utilization of hospital resources, and quality of patient care rendered at University of Michigan Health West. The role combines clinical, business, and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payment for services provided.

Requirements:

• Current and valid Michigan R.N. license; Bachelor of Science in Nursing preferred.
• Minimum of three years acute clinical nursing experience.
• Skill and proficiency in applying managed care principles and concepts to the utilization review process.
• Knowledge of and skill in the use of computers and related systems and software preferred.
• Skill in observation and critical thinking, demonstrated by effective decision making, and use of appropriate problem-solving methods.
• Skill in excellent interpersonal, oral, and written communications required. A high degree of professionalism is essential for all contact with patients, family members, clinical personnel, physicians, outside referral sources, and members of the community.
• Ability to make effective decisions, judgments and incorporate problem-solving methods.
• Ability to be persistent in working through and/or resolving issues and problems required.
• Ability to work independently and professionally, set priorities and take initiative while working efficiently and using good judgment required.

Essential Functions and Responsibilities:

Utilization Management:

1. Assess medical documentation for medical necessity using established medical necessity criteria to determine the appropriate level of care for neonate, pediatric, adolescent, adult, and geriatric populations.
2. Refers cases as appropriate to the Physician Advisor for medical necessity review.
3. Explores strategies to reduce length of stay and resource consumption while maintaining optimal patient outcomes. Takes action to achieve continuous improvement in both areas.
4. Obtains authorization for unscheduled/emergency admissions, as directed by health plan for both in-network and out-of-network payers. Communicates with surgical providers office to ensure authorization is obtained for planned surgical procedures.
5. Responsible to provide key clinical information to obtain authorizations from payers as needed.
6. Collaborates with the health care team regarding length of stay, treatment, and patient classification implications.
7. Identifies potential medical necessity denials in real time. Drafts and submits appeals for denials and seeks guidance from leadership and/or physician advisor as needed.
8. Communication with payers to obtain insurance authorization, schedule peer to peers, review of medical necessity denials, and submission of appeals.
9. Assists with the education of medical staff and other health care professionals regarding utilization of resources and regulations that impact the delivery of care, payer requirements and patient classifications.
10. Verifies and documents the outcome of the utilization review, payer response, and physician recommendations in the electronic record.

Clinical Performance Improvement:

1. Assists in the collection and reporting of resource and financial indicators including case mix index, LOS, avoidable days, readmission rates, denials and appeals.
2. Collects delay and other data for specific performance and /or outcome indicators as determined by the Director of Care Management.
3. Uses data to drive utilization review process improvement strategies.
4. Collaborates with medical staff, nursing staff and other members of the organization to ensure cost efficient delivery of care in the appropriate setting.
5. Supports and assists in facilitation of appropriate clinical documentation efforts.
6. Reviews medical record for issues related to quality, risk management and appropriate utilization of services.

Other:

1. Predictable and reliable attendance.
2. Performs other duties as assigned. These may include but are not limited to: Maintaining a current knowledge base of department processes, protocols, and procedures, pursuing self-directed learning and continuing education opportunities, and participating on committees, task forces, and work groups as determined by management.