Utilization Review Job at Nemaha Valley Community Hospital in Seneca
Nemaha Valley Community Hospital, Seneca, KS, United States
Job Description
JOB TITLE: Utilization Review DEPARTMENT: Nursing
JOB RELATIONSHIPS:
Responsible to: Director of Nursing
Responsible for: None
Interrelationships: Works cooperatively with all hospital departments and the Medical
Staff.
JOB SUMMARY:
To assure appropriate use of the hospital’s resources while striving to provide quality
patient care in the most cost effective manner.
JOB QUALIFICATIONS:
Experience: Minimum of 3 years previous experience as a Registered Nurse or Licensed Practical Nurse in an acute setting.
Education: Graduate of an accredited program of nursing
Req. Cert./ Registration and current license in the state where
Registration: employed, CPR certified, unit specified requirements.
Job Duties (this list may not include all of the duties assigned)
1. Adhere to established departmental policies and procedures, objectives, quality improvement, safety, environmental, infection control standards and mission, vision and values of Nemaha Valley Community Hospital.
2. Reviews medical records of patients for admission and continued stay criteria as identified by Milliman, and third party utilization review organizations.
3. Coordinates information to assure approval of medical necessity for admissions and completes documentation in the EHR as appropriate.
4. Document the appropriate Utilization Management information regarding levels of care, Milliman Criteria for Observation services, Inpatient services and appropriate length of stays.
5. Takes measures necessary to assure treatment and procedures are fully and accurately documented by the responsible/appropriate staff and/or physicians.
6. Works in conjunction with the Discharge Nurse to coordinate referrals of patient, family, or significant other ensuring that the needs of the patient and family are adequately met.
7. Coordinates with the Discharge Nurse, the ongoing comprehensive patient needs assessment beginning with admission and continuing throughout hospitalization.
8. Establishes and carries out a program of admission certification and continued stay review of patients in accordance with applicable statutes and regulations.
9. Assists in admission, transfer and dismissal procedures of the patient.
10. Works in conjunction with the Discharge Nurse and assumes the responsibilities of the Discharge Nurse in his/her absence.
11. May be required to function in direct patient care (staff nurse) activities as assigned.
12. Provide quarterly report on UR to the Medical Staff.
13. Identify and refer patients who have the potential need for discharge planning and follow-up.
14. UR screens the Medical Record of each patient admitted to the hospital to determine if, admission is medically necessary; if the setting and services requested are appropriate; and if there is the need for discharge planning intervention.
15. Continued stay review will be performed on all patients in the hospital. All patients are reviewed for medical necessity and appropriate use of services. Review is done on a daily basis and pertinent information is recorded in the chart.
16. Ensure that when there is a question of need for acute care in the hospital setting, the case is referred to the attending physician for alternate level care decision.
17. Will serve on the Chart audit and RAC committees.