Utilization Review Nurse Manager

The Utilization Review Nurse Manager is responsible for overseeing the compiling and reviewing the medical information for individual patients and the insurance coverage available to them. The Utilization Review Nurse Manager must be able to balance the quality of patient care with cost efficiency and consider the appropriateness/necessity of services prior to authorizing them or preparing cases for physician review.

Duties and Responsibilities

Oversees the general operation of the Utilization Review Department.

Manages the qualifications, competencies, staffing levels, workload and productivity, regulatory compliance, continuing education, performance evaluations, and onboarding process within the department.

Reviews current processes regularly to ensure maximum efficiency and effectiveness, including, but not limited to:

• Length of stay
• Long-stay patients
• Readmissions
• Denials
• Medicare Beneficiary Notice Compliance
• Condition Code 44 compliance
• Patient choice compliance

Avoidable Day Compliance

• Plans, assigns, and evaluates the work of subordinates engaged in Utilization Review activities.
• Organizes, assigns, and evaluates the Utilization Review Nurses.
• Reviews all observation charts regardless of pay or source to determine appropriateness and if they meet criteria for admission.
• Completes admission reviews for Medicare, Medicaid, and private insurance within allotted time frames.
• Builds program collaboration with physicians in areas of discharge planning and utilization review to allow continuous improvement in practices and education inline with medical standards.
• Identifies in-patient charts that do not meet established criteria and confers with the attending physician.

Assures pre-certification on all insurance and Medicaid patients as identified by applicable companies and policy and procedure.

Reviews all DMA6 and Level 1 PASSR for patients requiring nursing home placement. Communicates with nursing home staff concerning bed availability and where the patient will be transferred to.

Participates in interdisciplinary team meetings with all therapies involved in Swing Bed patients receiving skilled services.

Completes continued stay reviews for Medicare, Medicaid, and private insurance are on or before the assigned review date.

Initiates discharge planning on admission and follows through to ensure all physical, social and emotional needs of the patient are met, appropriate referrals are made, and the patient and family are insured continuity of care.

Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is evaluated based on appropriate screening criteria and standards. Serves as the liaison with the physician advisor for the referral of unusual/questionable cases, on referred cases for reconsideration, and in obtaining authorization for the issuance of denial letters.

• Assists Physicians in answering adverse determinations from third party payors.
• Reviews and maintains regular social service progress, indicating response to the treatment plan and/or adjustment to institutional life.
• Sends denial records and denial letters to appropriate entities.

Plans, develops, and implements procedures to fulfill the requirements and guidelines for an effective and timely Utilization Review system.

Confers with physicians, administrative personnel, and other disciplines in the hospital to coordinate the work of the unit, obtain information, answer questions concerning the necessity for utilization review, and develop review procedures.

Determines the need for and conducts in-service training to improve quality of admission and continued stay reviews, and to disseminate information concerning new or revised procedures.

Collaborates with a Professional Standards Review Organization representative to orient new staff to Federal laws and regulations pertaining to Medicare and Medi-Cal reimbursement.

Reviews, retrospectively, utilization review records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information.

Develops procedures for the compilation of information from medical charts concerning particular diagnoses, problems, procedures, or practitioner categories for medical care evaluation studies.

Prepares and analyzes reports on number and status of reviews, physician advisor referrals, and type of physician advisor determinations to determine if improvement in procedures or additional staff training is needed, and to make recommendations on potential areas for medical care evaluation studies.

Participates in the formulation of, and changes to utilization review procedures by assessing the effectiveness of the review system and providing information on policies and procedures.

Leads the Utilization Review Committee.

Leads Utilization Review Committee meetings to inform the committee of new or revised utilization review requirements, the impact of the requirements, and procedures to be implemented for compliance.

Acts as a technical resource person to subordinate staff concerning Federal regulations pertaining to Medicare and Medi-Cal reimbursement, aspects of medical treatment for unusual illnesses and diseases, and interpretation of review procedures and standards.

Provides input for the in-service training program by identifying areas of deficiency with staff and providers.

Maintains effective working relationships with unit physicians to facilitate the execution of the utilization review system.

• Suggests improvements using innovative and creative problem-solving skills.
• Processes notices for chart reviews from all third party payors.
• Completes retrospective chart reviews.
• Evaluates performance and provides feedback of subordinates.
• Maintains monthly records of admissions and discharges.
• Attends departmental staff meetings.
• Performs other job-related duties as requested.

Education/Qualification Requirements

Current RN or LPN license in the State of Georgia.

BLS Certification. (Must be obtained within 90 days of hire)

Experience

At least 2 yrs experience in Medical-Surgical Nursing, or equivalent combination of education and experience preferred but not required.

Previous experience in nursing and care/utilization management preferred but not required.

Language Skills

• Ability to read and communicate effectively in English, both verbally and in writing.
• Additional languages preferred.

EOE Statement

We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.