IA Utilization Review

Please only submit qualified candidates with a minimum of 5 years of experience in direct patient care along with a minimum of 3 years in a Utilization Review role. POTENTIAL REMOTE POSITION.Schedule: Standard business hoursM-F 8a-4:30pmWill discuss schedule expectations based on candidate and facility needsESSENTIAL FUNCTIONS1. Responsibility Statement: Provide Utilization Review coverage for the hospital patient care units.a. Assist with the admission and continued stay reviews on all patients admitted to the med-surg/ swingbed,behavioral health, ICU / PCU and OB units.b. Review medical records for clear admission orders, documentation of medical necessity for admission andcontinued stay criteria, using the appropriate Milliman care guideline criteria.c. Perform utilization review activities for Medicare, Medicaid, Private insurance and self-pay patients.d. Complete private insurance reviews for admission precertification and continued stay as required by the insurancecompany.e. Communicate with Patient Accounts on patient's level of care, insurance coverage, authorization numbers, andbenefit information.f. Enter insurance authorizations obtained into Paragon UR or Patient Management "Notes' tab.g. Prescreen all patients before being admitted to a swingbed/skilled level of care, gathering clinical information tomake sure the patient qualifies for a swingbed/skilled level of care.h. Communicate with the physician and nurse manager of the med-surg unit on any patient transferring from anoutside facility to SMH skilled/swingbed level of care.i. Coordinate communication with the nursing staff and write orders under the direction of the physician for outsidetransfers in to a skilled/swingbed level of care.j. Attend med-surg daily updates to remain appraised of patient conditions and to provide communication from UR.k. Attend Behavioral Health team meetings when needed, to remain appraised of patient conditions and to providecommunication from UR.l. Apprise the UR Coordinator of any UR issues that may be significance.m. Apprise the Risk Manager of any risk issues identified.n. Maintain patient confidentiality.2. Responsibility Statement: Assist with the Quality Management Committee & Medical Staff Quality Management Committee (QMC/MSQMC) review process.a. Assist with the blood transfusion monitoring done monthly, reviewing for medical necessity of blood transfusionsadministered, and referring cased to physician reviews as indicated.b. Assist with the Mortality and Morbidity (M&M) review, reviewing medical records of deaths that have occurred,completing an M & M worksheet, and completion of the physician review process.c. Assist with quality monitoring, i.e. Admission Review monitor, and other topics as indicated.d. Maintain peer review confidentiality.e. Assist with data collection of any focused review monitoring directed by the MSQMC.f. Assist with compiling Medical Staff peer review information for medical staff credentialing and reappointment.3. Responsibility Statement: Assist with Medicaid Managed Care Reviews.a. Assist with communication of Medicaid patients involved with Medicaid Managed care companies ensuringprecertification and continued stay reviews are completed for authorization of services and payment.b. Communicate w/ patient accounts on authorizations obtained with patient's level of cares.4. Responsibility Statement: Promote the Quality Services department.a. Participate positively in departmental staff meetings.b. Assure team approach.c. Assist with special project and committee work as assigned.

Shift: Mon-Fri

Specialty Type: Nursing

Sub Specialties: Utilization Review RN

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