Utilization Review - Registered Nurse (Weekend)

The Utilization Review RN will perform reviews of current inpatient services,
and determine medical appropriateness of inpatient and outpatient services
following evaluation of medical guidelines and benefit determination.
Collaborates with UM Specialists, Physician Advisor, and various departments
regarding medical necessity of hospital stays from admission authorizations to
discharge, including denials and appeals. Strong communication skills are
necessary to access available resources and communicate with providers and other
members of the interdisciplinary team. Active participation in program
development and process improvement efforts is an expectation.

Responsibilities

* Conducts inpatient admission, concurrent, and retrospective review for
Medicare and Medicaid beneficiaries as well as managed care and self-pay
patients based on CMS guidelines.
* Uses national medical necessity tool to screen for appropriateness for
inpatient level of care or observation services based on physician
certification including history and physical, treatment plan, potential
risks, and basis for expectation of a 2-midnight stay.
* Keeps current on all regulatory changes that affect delivery or reimbursement
of acute care services.
* Consistently identifies and records information on any
progression-of-care/patient flow barrier and communicates with care team as
necessary to notify of denial of continued stay so team can impact barriers.
* Collaborates with physicians and APRNs to influence appropriate utilization
of resources, accurate status determination, and transitions of care.
Educates members of the patient’s care team on the appropriate access to and
use of various levels of care.
* Represents utilization management at various committees, professional
organizations, and physician groups as needed.
* Promotes medical documentation that accurately reflects findings and
interventions, presence of complications or comorbidities, quality and safety
indicators, and patient’s need for continuing stay.
* Confers with attending physician and Physician Advisor if medically
unnecessary inpatient treatment is contemplated. Coordinates appeals to
denials as necessary.
* Serves as a resource person to physicians, nurses, billing office and other
external departments for coverage and compliance issues.
* Other duties as assigned

Education

* Bachelor's Degree - Graduate from school of nursing. - Required
* Bachelor's Degree - BSN - Preferred

Work Experience
* 3 Years - Clinical or managed care experience - Required
* Knowledge of medical necessity guidelines - Preferred

Licenses and Certifications
* Registered Nurse (RN) - State Licensure/Or Compact State Licensure - Licensed
in state of Missouri - Required Upon Hire

Travel Requirements
* Must be able to travel between various system facilities and off-site
locations as needed. - Required

Qualifications

Skills and Abilities

Essential Technical/Motor Skills

* Hand/eye coordination; speaks clearly; good hearing; computer
skills/telephone skills and voice recorder skills.
* Ability to read, write, and speak clearly.

Interpersonal Skills

* Must be able to teach, provide accurate and concise information, answer
questions, demonstrate excellent leadership skills, maintain positive
relationships with multiple customers, motivate and persuade others.

Essential Physical Requirements

* Physical requirements include standing, walking, and fine motor skills;
reaching for items; bend, squat, sit, and climb stairs.
* Sufficient strength and mobility to sit for long periods of time (depending
on assignment).

Essential Mental Abilities

* Critical thinking skills, problem-solving skills, negotiating abilities.
* Capable of determining appropriate response to emergency situations.
* Ability to focus and concentrate in order to correctly perform tasks despite
numerous distractions and interruptions.
* Ability to maintain professional demeanor to communicate and interact with
patients, customers and team members.

Essential Sensory Requirements

* Appropriate functional vision, hearing acuity.

Exposure to Hazards

* Eye and neck strain.

Other Skills and Abilities

Mosaic Life Care is a health care system in northwest Missouri. With a vision of
transforming community health by being a life-care innovator, Mosaic places the
holistic needs of patients first by providing the right care at the right time
and place, offering high value and quality health care.

Mosaic has a wide array of benefits to meet each employee’s individual needs.
Our benefits were designed by listening to people just like you. Mosaic also
offers several perks with a focus on ensuring our employees feel valued,
including concierge services, employee lounge, wellness programs, free covered
parking, free on-site and virtual health clinics and many more. When paired with
compensation and recognition, it is what continues to make us the employer of
choice for employees at any stage of their journey.