Utilization Review Nurse

Macon Community Hospital

Position Description

Department Name

Care Management

Employee Name

Job Title: Utilization Review Nurse

Effective Date

Reports to (Title): Care Management Director

Supervises

(Positions)

N/A

I have reviewed these job requirements and verify that I can perform all essential functions of this position. I understand that information regarding patients at this facility is confidential and is not to be disclosed without written authorization of the patient or authorized representative.

I will discuss patient’s information only in the course of my duties and never in open areas such as hallways, snack bar, etc., where it might be overheard by visitors or other patients, or outside of the hospital while off duty.

I also understand that information in some patient’s records may be governed by federal regulation and that disclosure of such information is punishable by fine or imprisonment, even after I leave the employment of the facility. I certify that I have completed HIPAA training and will honor all policies and procedures.

I understand that violations of these policies and procedures may result in sanctions. I agree to abide by all local, state and federal laws.

Employee Signature Date

1. Position Summary

Utilization Review

Works collaboratively with interdisciplinary staff internal and external to the organization. Participates in performance improvement and evaluation processes. Performs admission and continued stay reviews utilizing appropriate criteria and guidelines. Participates actively in appeals and denials processes.

Interacts with patients/families to identify needed support and referrals to appropriate outside organizations. Implements timely discharge processes. Collaborates in the development of clinical pathways and other protocols.

Works closely with nursing service to support and provide care when needed with Med/Surg Supervisor acting as consultant on clinical issues.

Utilization Review Nurse, (1) evaluates the appropriateness of admissions to the hospital, treatment rendered, length of stay, use of medical and hospital services and all related factors which may contribute to the effective utilization of hospital and physician’s services, (2) analyzes how utilization of hospital services affects the quality of patient care provided at the hospital, (3) assists with the assurance of proper continuity of care upon discharge and in conjunction with discharge planning, (4) endeavors to assure appropriate allocation of the hospital’s resources by striving to provide quality patient care in the most cost effective manner. Assume the responsibilities of the Social Services/Discharge Planning Coordinator when necessary.

Other

This position also coordinates the Peer Review function.

II. Position Requirements:

1. Licensure/Certification/Registration: Certification preferred in Case Management. Current registered nursing license in the State of Tennessee. Certification in Utilization Review or Utilization Management preferred.

2. Education: High School diploma, medical terminology, anatomy and physiology, training with Interqual criteria. Graduate from accredited school of nursing. BSN preferred.

100. Experience: 2-3 years experience in health care facility.

500. Special qualifications: Strong communication skills including the ability to communicate in a positive manner, verbally and in writing. Self-motivated, independent, professional, creative and dependable. Ability to function without supervision and to work with difficult personalities and situations within guidelines. Able to merge clinical and financial processes. Ability to work with others as a team.

III. Degree of Supervision Required: The Case Manager is expected to perform most job duties independently and in accordance with established departmental and hospital policies/procedures.

IV. Ages of Patients Served: This position requires competence in assessment, treatment, and/or care for the age groups indicated. The staff member must be able to demonstrate the knowledge and skills necessary to provide care, based on physical, educational, safety, and related criteria, appropriate to the age of the patients served. The skills and knowledge needed to provide such care may be gained through education, training, or experience.

Birth - 1 Year

Infant

X

2-12 Years

Pediatric

X

13-18 Years

Adolescent

X

19-69 Years

Adult

X

70>

Geriatric

X

N/A

No responsibility to treat or care for patients

V. Working Conditions:

Hospital rooms, common areas, clinical departments and hospital grounds. Potential hazards include:

Exposure to

None

Some

Frequent

Very Frequent

Exposure to

None

Some

Frequent

Very Frequent

• toxic/caustic

chemicals

X

• blood or body

fluids

X

• extreme

conditions,

hot or cold

X

• communicable

diseases

X

• dust/fumes/

Gases

X

• unprotected

heights

X

• moving

mechanical

parts

X

• CRT (computer)

monitor

X

• potential

electric shock

X

• frequent,

repetitive motions

X

• x-ray electro-

magnetic

energy

X

• Other (as listed)

radiation

• high pitched

Noises

X

• needles or

other sharp

objects

X

VI. Physical Requirements: Requires corrected hearing and vision to within functional ranges. Requires standing/walking, usually conducted over linoleum or carpeted floor. May be required to sit for long periods of time. Finger dexterity required.

Occasional pushing, pulling, climbing, bending stooping, twisting, using arm, leg and back muscles may be required. May be expected to lift less than 25 pounds. Manage stress appropriately, handle multiple priorities. Make decisions under stress. Work alone and manage anger, fear, hostility and violence of others appropriately.

VII. Personal Protective Equipment:

This position requires the use of personal protective equipment during various tasks/activities. Personal protective equipment

includes, but is not limited to, gloves, masks and safety glasses.

VIII. Performance Standards:

Rating Standard

U - Unacceptable Work performance is inadequate and inferior to the standards of performance required for the position. Performance at

this level cannot be allowed to continue.

IN - Improvement Needed Work performance does not consistently meet the standards of performance for the position. Serious effort is needed to

improve performance.

ME - Meets Expectations Work performance consistently meets the standards of performance for the position.

EE - Exceeds Expectations Work performance is consistently above the standard of performance for this position.

O - Outstanding  Work performance is consistently superior to standards required for the job.