Clinical Utilization Review RN

Under general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with the health plan, clinical providers (HMH Physicians/NPs) and care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates as a team to ensure that medical records support the level of services being delivered.

ESSENTIAL JOB FUNCTIONS

Every effort has been made to make this job description as complete as possible.  However, it in no way states or implies that these are the only duties the incumbent will be required to perform.  The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

• Performs initial, concurrent, discharge and retrospective reviews.
• Uses evidence-based medical guidelines to determine the medical appropriateness of inpatient and outpatient services.
• Assesses patient needs; Uses knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients
• Identifies, escalates and resolves complex cases or issues as required. 
• Reviews medical records to verify that the content supports an appropriate level of care (inpatient, observation, bedded outpatients) or type of service.
• Alerts and collaborates with appropriate Utilization Review, Physician leadership and/or Provider Team personnel concerning patients who do not meet medical appropriateness criteria. 
• Coordinates with necessary parties when there are potential or actual denials. Facilitates appeals or the delivery of appeal instructions when denials occur. 
• Facilitates authorization process for admissions and continued stays.
• Uses knowledge of nursing process and pathophysiology to anticipate discharge needs. May participate in discharge planning through discussions with the care team as needed.
• Communicates issues or trends with specific entities, providers or payors to the appropriate leadership.
• Provides support to complex cases or escalations within scope of licensure or refers them to appropriate leadership.
• Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.
• Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies, and procedures to continuously enrich care coordination efforts and ensure evidence-based processes are utilized. 
• Abide by HMH Legal Compliance Code of Conduct.
• Proactively monitors hospital admissions for medical necessity and appropriate hospitalization status utilizing hospital approved criteria.
• Maintains patient confidentiality and appropriate handling of PHI.
• Maintains a safe work environment and reports safety concerns appropriately.
• Performs all other related duties as assigned.

LATITUDE, CONTACTS/INTERACTIONS

All positions of Huntsville Memorial Hospital are part of an interdisciplinary team, and as such, participate in the care and service delivery process through effective interaction with other team members.  Primarily interacts with hospital staff, medical staff, patients, and visitors.

Education: Graduate of a school of professional nursing or vocational nursing.

Experience: Must have a minimum of 2 years Acute Care Hospital Utilization Review experience utilizing MCG or Interqual guidelines. ER/ICU background and/or Case Management experience is a plus. Experience should include reviewing for medical necessity/severity of illness for initial hospitalization as well as continuous stay reviews. Experience with Electronic Health Records, Microsoft Excel/Word, and Google Sheets is preferred.

Licensure/Certification: Current licensure as a Registered Nurse in the state of Texas.  Certification with the Fellowship of American Academy of Case Managers (FAACM) preferred.

Required Skills: Must have strong analytical, data management, organizational and time management skills.  Must have knowledge of applicable federal and state regulatory requirements including: TDI, CMS, & HHSC. This role requires excellent computer and verbal skills as you will be interacting with payers, physicians and other clinical staff.  M-F with weekend rotation.

PHYSICAL DEMANDS AND WORKING CONDITIONS

Frequent: sitting, standing, walking, & reaching.

Occasional: lifting, carrying, bending, & squatting,

Visual and hearing acuity required.  Work is inside, with good ventilation and comfortable temperature.

Possible exposure to: toxic/caustic chemicals or detergents, communicable diseases, blood borne pathogens.

• Health Care Plan (Medical, Dental & Vision)
• Retirement Plan (401k, IRA)
• Life Insurance (Basic, Voluntary & AD&D)
• Paid Time Off
• Short Term & Long Term Disability
• Training & Development
• Wellness Resources