RN- Utilization Review

Job Description

At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.

As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors.

UC Health is committed to providing an inclusive, equitable and diverse place of employment.

The RN-Utilization Review nurse will use established criteria and policy/procedures to perform pre-admission, admission, and continued stay reviews on inpatient and observation cases in a timely manner. UR Nurse will work with hospital Care Management staff, Social Work, and Revenue Cycle team members, as well as with managed care agencies to assure certification of the patient's entire stay so that hospital receives maximum reimbursement.

Responsibilities

Productivity:

Maintains productivity at or above the defined standard for the specific area of UR.

Reviews and evaluates assigned cases within one business day and as appropriate throughout the patient's stay.

Accuracy:

Reviews and evaluates physician orders at the time of admission or upon first review for the correct inpatient vs observation status as it relates to regulatory requirements (such as CMS 2 MN rule), established review criteria, and patient's clinical symptoms and findings.

Enters all utilization review data into the appropriate fields/screens in the Epic system as outlined in policies/procedures.

Maintains accuracy at or above the defined standard for the department.

Communication:

Works with physicians, as needed, to ensure that documentation supports level of care criteria and medical necessity. Escalates as appropriate to physician advisor or Utilization Review leadership.

Communicates findings to managed care companies and other members of the revenue cycle team to assure certification of days for reimbursement. Assists in peer-to-peer denial/appeal process while patient is still in the hospital, aggressively advocating on the patient and hospital's behalf.

Collaborates with the Care Management/Social Work team on payer issues related to admission or continued stay to resolve identified issues and to facilitate discharge planning.

Job Knowledge:

Maintains current knowledge and is capable of applying InterQual or MCG criteria in the review process.

Serves as a consistent resource regarding utilization review issues. Participates in educating members of the patient care team relative to managed care and/or regulatory guidelines for utilization review.

Demonstrates ability to creatively and independently problem solve, intervene at appropriate levels, and evaluate outcomes of intervention on a consistent basis.

Keeps abreast of current rules, regulations, policies and procedures related to third party payers, CMS, Joint Commission and other regulatory agencies.

Quality/Performance Improvement:

Participates in data collection and analysis, as required, related to utilization activities such as (but not limited to) avoidable days, LOS, readmissions.

Supports performance improvement initiatives and participates in identification of opportunities for improvement.

Professional Development:

Attends appropriate clinical and professional organizations, workshops and meetings as required. Completes all required internal education.

Remains current on clinical advancements related to specific patient populations and changes to established criteria sets.

Proactively seeks to understand areas/roles outside of immediate role.

Qualifications

Minimum Required: RN with current license. Preferred: BSN | Current RN license in Ohio. | Minimum Required: 3 - 5 Years equivalent experience.

Join our team to BE UC Health. Be Extraordinary. Be Supported. Be Hope. Apply Today!

About UC Health

UC Health is an integrated academic health system serving Greater Cincinnati and Northern Kentucky. In partnership with the University of Cincinnati, UC Health combines clinical expertise and compassion with research and teaching-a combination that provides patients with options for even the most complex situations. Members of UC Health include: UC Medical Center, West Chester Hospital, Daniel Drake Center for Post-Acute Care, Bridgeway Pointe Assisted Living, University of Cincinnati Physicians and UC Health Ambulatory Services (with more than 900 board-certified clinicians and surgeons), Lindner Center of HOPE and several specialized institutes including: UC Gardner Neuroscience Institute and the University of Cincinnati Cancer Center. Many UC Health locations have received national recognition for outstanding quality and patient satisfaction. Learn more at uchealth.com.

Same Posting Description for Internal and External Candidates