Utilization Review - Registered Nurse (Weekend)
Mosaic Life Care
20 hours ago
Full-time
Remote friendly (Saint Joseph, Missouri, United States)
Worldwide
Registered Nurse
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.
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.