The Utilization Review Nurse monitors, evaluates and assists in the maintenance and improvement of efficient utilization of hospital resources through performance of pre-admission/admission and continued stay medical record reviews. Responsible for coordinating communication between the hospital and third-party payors to ensure care delivered in the hospital setting will be reimbursed. Minimizes denials by third-party payors by communicating clinical information in a timely manner. Intervenes to reduce and eliminate service delays and non-acute hospital days. Monitors the quality of documentation and services provided and makes recommendations for improvement.
This job description is intended to identify some of the primary duties and responsibilities. Mayers Memorial Hospital District reserves the right to modify, supplement, delete or augment the duties and responsibilities specified in this position description, at MAYERS MEMORIAL HOSPITAL DISTRICT’S sole and absolute discretion.
Bachelor’s Degree in nursing
Maintain an active Ca nursing license
Successful completion of quality or Utilization Review certification examination
One-two years’ experience as Utilization Review RN preferred
Experience in the application of Utilization Review activities and medical record reviews
Working knowledge of Microsoft Office products (word, excel, power point)
Possesses independent work habits, is self-reliant and self-directed.
Possesses the ability to learn, adapt, and change as required by the job functions.
Able to work effectively in situations of high stress and conflict and communicate the goals and outcomes of case management.
Quality Improvement principles and Risk Management objectives
Exercises good public relations skills.
Strong clinical skills, assessment, and good professional judgment, as well as broad-based knowledge of medical management, nursing management and medical terminology.
Demonstrate the ability to read and comprehend government regulations and contracts
Demonstrate familiarity and knowledge of medical records organization and procedures.
Professional behavior is demonstrated, both when on duty and as a representative of MMHD outside of normal work hours.
Ability to work with others, at all levels within the organization, and collaborate effectively.
Above-average interpersonal, problem-solving, and written and oral communication skills.
A positive working relationship with patients, visitors, and facility staff is demonstrated.
Organizational ability and time management is demonstrated.
Produces deliverable products on time, within budget with minimal direction.
Demonstrates the ability to compile and organize data using Microsoft Office Applications. Ability to make appropriate recommendations or conclusions, given the data obtained.
Maintains an organized set of records, upon request, for the functions that are performed within the scope of this job.
Communicates appropriately and clearly to directors, managers, and coworkers.
Performs all assigned tasks accurately, to include proper spelling and grammar, reference materials, and minimal mathematical calculation.
Takes direction from others to include those employees of other departments with which he/she works on a temporary basis in accordance with the chain of command.
Maintains all information as confidential as appropriate, to include payroll, personnel information, and other information obtained during the course of performing job duties that is confidential.
Demonstrates ability to effectively use office machines in the performance of job functions.
Answers phone calls, assists public, and forwards appropriately if necessary and in a professional and friendly manner.
Other duties as assigned.
Keeps current with all government rules and regulations (federal and state) that impact the Utilization Review program; evaluates their impact on needed operational changes and communicates this information on a timely basis to all appropriate departments.
Accurately applies appropriate medical necessity criteria to all cases reviewed to determine level of care, severity of illness and service intensity.
Completes admission reviews within 24 hours or first business day following admission
Performs concurrent chart review hospital-wide in accordance with department protocol and productivity standards and maintains documentation on all cases.
Ensures verification of patient benefits when required.
Completes verification and correction of patient status when indicated.
Monitors outpatients receiving observation services per hospital policy.
Discusses cases that do not meet acute level of care criteria with the attending physician and members of the health care team and assists with problem solving and recommendation regarding documentation needs or alternate levels of care.
Consults with involved health care professionals to affect timely discharge.
Actively influences physician practice patterns to optimize patient outcomes.
Treats all information obtained while completing the review process or carrying out the other aspects of the Utilization Review program with strict confidentiality.
Refers suspected quality of care or risk issues to the department Director of Nursing or Director of Quality as appropriate.
Documents all reviews performed, aggregates data, and identifies trends as appropriate; provides summary reports to appropriate leadership and committees. Assists with recommendations and implementation of policies and procedures.
Identifies appropriate cases for issuance of hospital-initiated notice of non-coverage (HINN) to patients and/or their representatives, and coordinates with onsite Financial Counselor to assures the recipient is aware of his/her rights for a reconsideration.
Attends committee and department meetings to communicate Utilization Review findings for input and action.
Serves as a resource for Utilization Review issues. Conducts educational programs relevant to Utilization Review for hospital and medical staff.
Assists and educates patients and/or families with questions regarding insurance certification requirements.
Participates and facilitates concurrent and retrospective appeal process for third-party payor denials.
Identifies need for physician advisor intervention and facilitates physician advisor review.
Performs the assigned Utilization Review functions per department standard and essential department competencies as outlined in the performance plan. Key result areas include: Quality and thoroughness of concurrent review findings.
Productivity/Efficiency: number of reviews completed per day.
Data collection and analysis of Utilization Review findings for trend identification.
Implementation of system improvements.
Interrelates with physicians, nurses, managers and other hospital personnel.
Maintains department specific accountabilities as determined, maintained, and housed within each unit’s Scope of Service.
Identifies opportunities to improve patient experience. Participates in projects/programs designed to enhance service delivery and patient satisfaction.
Adheres to dress code; appearance is neat and professional.
Completes annual education requirements if applicable.
Maintains regulatory requirements.
Wears identification while on duty.
Attends annual evaluation and participates actively in this process.
Reports to work on time and as scheduled; completes work in designated time.
Attends all meetings as appropriate.
Exhibits the mission, ethics, and goals of Mayers Memorial Hospital District in the performance of job duties.
Willingness to work beyond normal working hours and in other positions temporarily when necessary.
Is involved with personnel, visitors and government agencies, etc., when necessary.
Must function independently, have personal integrity, have flexibility and the ability to work effectively with other personnel, clients and support agencies.
Sits, stands, bends, lifts, walks and moves intermittently during working hours.
Able to lift 20 lbs.
About Mayers Memorial Hospital District
Here at Mayers Memorial Healthcare District we value your health, well being and happiness. Our dedicated staff is here to provide quality, compassionate healthcare. We are "friends and family caring for friends and family."
MMHD is located near the junction of the Cascade and Sierra mountain ranges in the northeastern California. Mayers has been providing high quality healthcare since 1956. With facilities in the rural communities of both Fall River Mills and Burney, we are here to provide quality care for all the residents and visitors of our service area.