RN Utilization Review
Responsibilities include but are not limited to: Concurrent and retroactive chart review, performed for medical necessity as well as for effectiveness and appropriateness of admission, length of stay, and utilization of hospital resources. Knowledge of state and federal guidelines and criteria for determining medical necessity for admission, level of care, utilization of resources and continued length of stay is required. Bedside patient care is not a function of this department, however, clinical knowledge of signs, symptoms, treatments, therapies, expected outcomes, and the discharge needs of patients in all age groups is necessary. The Utilization/Case Manager exercises discretion and independent judgment regularly in the performance of this position. They must display assertiveness and the ability to communicate effectively with patients, staff and physicians. They will be required to work a weekend every four to six weeks. Must be able to perform jobs in all patient care and operational areas subject to reasonable accommodations. They must also be able to employ all mandatory safety devices and procedures. This is a non-union position. See Essential Job Functions.
Education required to qualify for license as a registered nurse.
Current California Registered Nurse License.
Current BLS Certification
ESSENTIAL JOB FUNCTIONS:
1. Review any potential admission, both emergent as well as scheduled/elective to provide timely any authorization and/or medical necessity needs to meet national standards and contractual requirements.
2. Review of patient care including prospective, concurrent and retrospective review of medical records.
3. Monitor and evaluate clinical services provided with a goal to achieve timely, medically necessary, and cost-effective quality care.
4. Monitor and investigate potential under- and over-utilization of resources.
5. Investigate timeliness of service, lack of access, and duplication of services.
6. Maintain case files, preserving member and provider confidentiality.
7. Reviews and collaborates with physicians and payor groups regarding patient condition, level of care, discharge plans, and length of stay.
8. Makes recommendations to physicians to affect change in patient status, when needed, which would comply with established guidelines and criteria.
9. Makes recommendations to physicians when medical necessity is no longer being met and suggests discharge or lower level of care.
10. Collaborates closely with Other Case Managers, Physician offices, ancillary departments, and the Nursing team to assure smooth, timely and efficient intake of patients for all levels of care.
11. Participates in Utilization Management Committee Meetings and Interdisciplinary Patient Care meetings.
Human Resources/Performance Improvement / Information Management
- Maintains awareness and participates in Continuous Quality Improvement (CQI) to ensure a safe patient environment.
- Attends and actively participates in team conferences and staff meetings, as assigned.
- Participates actively in orientation of new employees and on-the-job training of assigned personnel, as assigned.
- Adheres to all policies and procedures including but not limited to, the hospital Code of Conduct and Corporate Compliance Program, safety rules, Joint Commission standards, California Department of Public Health (CDPH) regulations and any other regulatory agency.
- Provides methodology for dissemination of information providing opportunities for discussions of division problems, and orientation of new projects or procedures, as assigned.
- Performs all tasks demonstrating service excellence to both staff and customers.
- Demonstrates, supports, and models the mission, vision, values and code of conduct
- Communicates appropriately and effectively to support the department mission.
NON-ESSENTIAL JOB FUNCTIONS:
- Willingly performs other duties as assigned or requested.