Utilization Review Coordinator
Blanchard Valley Regional Health Center

Job Info

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PURPOSE OF THIS POSITION

The purpose of this job is to carry out concurrent utilization review activities under the direction of the Utilization Review Committee. Monitor and report variances in quality control.

JOB DUTIES/RESPONSIBILITIES

Duty 1: Accountable for daily caseload of patients including new admissions and discharges and the coinciding admission status and concurrent chart review of daily caseload.

Duty 2: The UR nurse collaborates with insurance companies for all inpatient/observation patients to maintain appropriateness of care levels and necessity of utilization in compliance with established criteria.

Duty 3: The UR nurse works daily with the Registration and Pre-Cert departments to obtain and ensure bidirectional insurance communication.

Duty 4: The UR nurse attends daily rounds with other health care professionals to discuss various aspects of individual patient care to ensure delivery of high quality, efficient and cost effective care and assist in discharge planning.

Duty 5: The UR nurse on an ongoing basis communicates effectively with other healthcare disciplines, patients and their families as needed, during a patient's hospitalization so that appropriate levels of care and utilization of services are maintained.

Duty 6: The UR nurse works with the Utilization Review Physician Advisor to bring to resolution utilization issues and/or length of stay issues not resolved through direct discussion with the patient's own physician.

Duty 7: The UR nurse in a timely manner works with physicians to resolve denial/potential denial issues by making phone calls, writing appeal letters, and sending documents to insurance companies to avoid penalties or denials of reimbursement.

Duty 8: The UR nurse on a quarterly basis to maintain compliance with federal guidelines: develops the agenda for the UR/HIS/BYLAWS Committee, organizes information packets, distributes packets to committee members, attends the meetings, share information and answer questions regarding utilization of services and assists with the yearly review of the UR Plan.

Duty 9: The UR nurse as assigned participates in various committees and meetings to contribute information regarding utilization of services and quality of healthcare for the purpose of improving patient care and outcomes.

Duty10: The UR nurse evaluates the psychosocial needs of patients in a timely manner to assist in discharge planning, referral to other agencies/programs, or referral to the social work department. Also, provides Advanced Directive information to patients, family members.

Duty 11: The UR nurse, through concurrent chart review, issues or delegates the issuing of the following forms if applicable: BPCI-A notification, IMM (first or second), and MOON. The UR nurse also provides the following services to the patient if applicable: Disease specific education, community resource education and referral to appropriate inpatient and outpatient services.

Duty 12: The UR nurse participates in the readmission review process and works with the interdisciplinary team to identify patients who are readmitted or at risk for readmission and intervenes accordingly.

Duty 13: The UR nurse is available as a resource to the unit which they are serving on any given day, providing assistance as needed to the interdisciplinary team. The UR nurse participates in an on-call rotation and is available after hours/on weekends, or on an as needed basis.

REQUIRED QUALIFICATIONS

• Licensed Registered Nurse with significant clinical background required
• Positive service-oriented interpersonal and communication skills required.
• Individual must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served on his/her assigned unit/department. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient status. Must be able to interpret the appropriate information needed to identify each patient's requirements relative to their age-specific needs and to provide the care needed as described in the area's policies and procedures

PREFERRED QUALIFICATIONS

• Bachelor's degree in Nursing preferred

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent walking, lifting, bending, climbing, squatting, kneeling, twisting, sitting and standing. The associate will be required to walk for up to one hour a day, sit continuously for six hours a day and stand for one hour a day. The individual must be able to lift ten pounds and reach work above the shoulders. The individual must have good eye-hand coordination and fine finger dexterity for simple grasping tasks. The individual must have excellent verbal communication skills to perform daily tasks. The associate must have corrected vision and hearing in the normal range. The individual must be able to operate a motor vehicle for business travel and community involvement.

*BVHS *PRN


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