Utilization Review Nurse- Care Coordination Department

1. Clinical Review & Level of Care Determination

• Performs initial, concurrent, and discharge utilization reviews to determine the appropriate patient status (inpatient, observation, outpatient).
• Applies InterQual, MCG, or payer-specific criteria in accordance with CMS regulations and the Two-Midnight Rule.
• Collaborates with admitting providers to obtain timely admission orders and correct patient status when discrepancies arise.
• Ensures MOON, IMN, HINN (etc.) notices are issued and documented per policy.

2. Payer Communication & Authorization Management

• Conducts timely payer notifications with complete reviews and all supporting clinical documentation via fax or payer portal.
• Provides clinical updates and facilitates peer-to-peer reviews as required.
• Maintains documentation of all payer interactions in Cerner.
• Securely maintains all relevant login credentials for all payer portals.
• Demonstrates proficiency in navigating payer portals to efficiently retrieve and submit required data.

3. Collaboration with Clinical Team

• Discusses cases with the attending MD when a clinical review does not meet inpatient medical necessity at the first-level review to obtain additional clinical information and documentation to support inpatient level of care; if the case still does not meet criteria, sends it to the Physician Advisor for a second-level review.
• Forwards cases requiring secondary physician review to the appropriate resource (e.g., Physician Advisor).
• Resolves discrepancies at the time of review or escalates unresolved issues to the Physician Advisor and departmental leadership.
• Coordinates with the care team to change patient status as needed.
• Notifies the care team when a patient does not meet medical necessity per InterQual, MCG guidelines, or the Two-Midnight Rule and escalates appropriately.

4. Compliance & Performance Standards

• Adheres to all federal, state, payer, and hospital compliance requirements related to utilization management.
• Maintains confidentiality of patient information in accordance with HIPAA.
• Meets productivity standards, including review volume, timeliness, and documentation quality.

5. Hybrid Work Standards and Accountability

• Adheres to the standards outlined in the Nuvance Health Remote Work Program Policy when utilizing a hybrid work arrangement.

Maintains and models organization values.

Demonstrates regular, reliable and predictable attendance.

Performs other duties as required.