Utilization Review RN Full-Time Days New

Employment Type

Full time

Shift

Day Shift

Description

GENERAL SUMMARY AND PURPOSE:

Provides hospital case management/utilization review and discharge planning collaboratively determining level of care needs beyond acute care, providing decision support to patients/families and physicians, managing patient and family expectations, and ensuring a smooth transition to the next level of care and services. Coordinates the integration of social services into patient care as appropriate. Coordinates the hospital activities concerned with case management/utilization review and discharge planning. Adheres to departmental goals, objectives, standards of practice, and policies and procedures. Ensures quality patient care and adheres to regulatory compliance. Provides concurrent assistance and support to physicians and other clinical members of the health care team in coordinating the delivery of services for a select group of patients. To help achieve quality clinical and cost outcomes, incorporates real-time contacts with physicians, nursing, and ancillary care givers to establish specific treatment, cost, and transition targets and to facilitate transition planning.

Skills, Knowledge, Education And Experience

Colleague must have an RN license, as defined by their primary work state (Idaho or Oregon)

• IDAHO ONLY: Multistate licenses must establish residency with the Idaho Board of Nursing within 60 days from hire.
• All colleagues must provide licensure or proof of application in process for an Oregon RN license within 90 days of the hire date.
  
  

BSN required. Master's degree preferred. A minimum of 2 years of varied hospital clinical experience is required. Experience in case management, home health, and/or insurance industry preferred.

• xperience with applying InterQual and MCG medical necessity criteria
• Experience with communicating directly with health insurance companies electronically and verbally
• Experience with patient class order management
• Experience with Epic Utilization Review functions preferred
• Experience with direct conversations with providers
• Experience with Behavioral Health diagnoses/treatments preferred
• Knowledge of CMS regulatory requirements for Utilization Management as well as payer specific rqeuirements
• Works in coordination and collaboration with Clinical Resource Associates and Utilization Review RNs at Boise and across SAHS
  
  

Hybrid position. Onsite and remote work to be determined by the manager and needs of the department

Essential Functions

Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions. Demonstrates knowledge and skills to competently care for all assigned age groups (Neonate, Child, Adolescent, Adult, Geriatric as applicable). Revenue Management: ensures the accuracy of documenting services and supplies provided to the patients. Coordinates the integration of social services/case management functions into patient care, discharge, and home planning process with other hospital departments, external service organizations, agencies and healthcare facilities. Completes a screening/assessment of physician assigned cases to determine medical necessity/status determinations and transition needs. Reassesses, monitors, and modifies transition needs as appropriate. Conducts concurrent medical record review using established medical necessity criteria to determine correct level of care for acute patients. Assists physicians with completing transfer and discharge orders. Maintains knowledge of federal, state, and private agency review requirements and regulations. Provides education to all health care team members including physicians regarding requirements to meet regulatory standards. Promotes effective and efficient utilization of clinical resources from admission to discharge. Initiates and presents "denial letters" as appropriate. Completes PASRRs for admission to skilled nursing facilities. Delivers Condition Code 44 letters to patients and educates them on Medicare benefits. Researches and locates resources for patients for example: assistance in competing medication applications for financial assistance through pharmaceutical companies, works closely with our Patient Financial Advocates in the Medicaid pending process, and works closely with outside facilities to obtain equipment in situations when patients have limited funding available to them. Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, cases, and desired patient outcomes. Introduces self to patient and family and explains clinical resource manager role and the process for patient and family to contact clinical resource manager. Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient's and family's ability to make informed decisions. Participates in multidisciplinary patient care rounds and/or conferences as appropriate to review treatment goals, optimize resource utilization, provides family education and identification of post-hospital needs. Utilizes physician advisor referral as appropriate. Adheres to department established process in reviewing 30 day re-admissions. Follows established patient choice policy. Documents assessment of primary and back up plans along with communications to patient, family and care team. Documents interventions taken to meet the needs of their individual patients in Power Chart. Actively participates in department staff meetings and department sub teams.

Ensures discharge planning compliance with Medicare Conditions of Participation/regulations and Joint Commission standards

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

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