Under the direction of department leadership, the Utilization Review/ Management RN. This position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, and coordination to decrease avoidable denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments.
Essential Job Functions
Supports and models behaviors consistent with Billings Clinic's mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental, and outside agency requirements.
The responsibilities of the UR case manager are listed below, in order of priority and intended to ensure effective prioritization of tasks.
Priority 1: Reviews New Admissions, Observation and Outpatient Cases
Prioritize reviews of all OBS and bedded Outpatients
Communicate with attending physician to discuss case and obtain information not documented in record, when OBS cases do not meet payer criteria or OBS 24 hours
Communicate with attending physician for OBS patients meeting medical necessity for inpatient level of care to obtain inpatient order
Communicate with Case Manager to understand discharge plan and barriers to discharge on OBS and Outpatient in a Bed patients
Participate in daily OBS call and communicate why patient is here, what we need from the team to get the patient to the next level of care, and expected discharge plan
Ensure that admission review is completed on assigned units/worklist using payer MCG or CMS 2 Midnight Rule within 24 hours of admission
Identify incomplete reviews from worklist
Validate OBS orders daily for new admissions, within 24 hours
Ensure order in chart coincides with the payer review, CMS 2 Midnight Rule, or payer authorization for status and level of care
Priority 2: Performs Utilization Review (UR) Activities
Completes concurrent Level of Care (LOC) & status reviews utilizing payer criteria to assure all days of hospitalization are covered/certified or meet CMS 2 Midnight Rule (as appropriate) at minimum of every 3 days or more frequently based on payer requirements
Reviews observation patients at a minimum twice a day. Communicates with attending on medical plan and Case Manager on discharge plan to expedite progression to next level of care or discharge
Discusses case with attending when payer authorization does not match status or level of care.
Obtains information not documented in the EMR and requests documentation of medical necessity to support appropriate status (IP, OP, OBS) and level of care (Med-surg, SDU, ICU, etc.)
If attending is unable to provide additional clinical information supporting status or LOC, escalate case to the physician advisor for second level review as early as possible and before leaving for the day
Communicates to Case Manager any discrepancies on status or level of care based on medical necessity and/or payer authorization discrepancies
Communicates to Case Manager on current outliers, potential outliers, and denials
Identifies reviews that need to be completed on assigned floors and follows all assigned patients through completion and submission of Discharge Summary
Assesses if all days are authorized/certified by respective payers and communicate any issues/denials to attending physician, CM, and department leadership
Conducts UR until all tasks are completed; indicates UM Complete in authorization and/or certification
Communicates with payer UR representatives on status/level of care authorizations that do not match MCG review
Denotes relevant clinical information to proactively communicate with payers for authorizations of treatments, procedures, and Length of Stay; sends clinical information as required by payer
Notifies appropriate parties of any changes in financial class including conversions, Hospital-Issued Notices of Noncoverage (HINN), Condition Code 44, and Important Message from Medicare (IMM).
Follows department procedures and policies for Condition Code44, Physician Advisor review, and HINN processes
Documents Avoidable Days/Delays, per department process/procedure/policy
Priority 3: Maintains an Active Role in Denial Prevention and Management
Uses payer MCG criteria and supporting documentation to justify the patient's medical necessity for observation, admission and/or continued stay
Proactively interacts with payers and proactively sends clinical reviews to prevent inpatient denials
Proactively communicates with payer UM representatives on denials and coordinate peer to peer review with payer's medical director
Initiates and coordinates peer to peer reviews on all concurrent denials
Understands payer requirements and government regulations to ensure compliant, safe, and cost-effective healthcare
Priority 4: Identify Prolonged LOS patients, readmission, or complex discharge needs patients
Identifies Prolonged LOS patients or complex patients/situations and communicate to the CM and/or Social Worker as appropriate
Priority 5: Escalation
Refers cases that require second level review to Physician Advisor, Manager, and Director per department process or procedure
Discusses status/level of care and payment barriers with attending for resolution, if unsuccessful, escalate to department leadership and Physician Advisor, per department process or procedure
Insurance and Utilization Management
Maintains working knowledge of CMS requirements and readmission penalties
Maintains working knowledge of insurance/payer benefits
Documentation
Documents accurately and in a timely manner in the Electronic Medical Record per program guidelines
Utilizes standards of professional practice in all documentation and communication consistent with organization/department policy as well as the Board of Nursing and ethical guidelines established and universally supported by the nursing profession
Assures documentation and patient information is secure and maintained in accordance with Billings Clinic policy, HIPPA, state and federal guidelines
Professional Accountabilities
Participates in continuing education, department planning, work teams and process improvement activities
Maintains current Licensure
Adheres to department and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols and safety
Demonstrates the ability to be flexible, open minded and adaptable to change
Maintains competency in organizational and departmental policies/processes relevant to job performance
Utilizes standards of professional practice in all communication with patients, support systems and colleagues consistent with the Board of Nursing and ethical guidelines established and universally supported by the nursing profession
Maintain utilization review data, as assigned by department.
Performs all other duties as assigned or as needed to meet the needs of the department/organization
Minimum Qualifications
Education
4 Year / Bachelors Degree Graduate of an accredited school of nursing, bachelor's degree required
Experience
3 years of hospital clinical experience.
1 One (1) year of Billings Clinic experience, preferred
License and Certification
Healthcare Provider and ACLS CPR certifications
Current Registered Nurse license in the state of Montana
| Location | BILLINGS, MT |