Utilization Review RN - Sign on eligible

Navajo Preference Employment Act

In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference.

Overview

POSITION SUMMARY

The Utilization Review (UR) Nurse ensures that patients receive appropriate care by verifying medical necessity, confirming the correct patient status, and monitoring the ongoing need for services while working to reduce unnecessary length of stay and prevent delays; they support accurate clinical documentation for proper reimbursement, coordinate with providers and the care team on discharge planning and transitions, manage resource use to control costs, communicate with payers to prevent denials, and ensure compliance with CMS and Joint Commission requirements while contributing to reporting and quality improvement efforts. They also serve as a key liaison between clinical care, finance, and regulatory requirements, helping align patient care with both quality standards and reimbursement rules. Ultimately, their role has a direct impact on patient outcomes, hospital efficiency, and the organization's financial performance.

Qualifications

NECESSARY QUALIFICATIONS

Education:

• Bachelor's Degree in Nursing

License/Certification:

• A valid, current, full and unrestricted Professional Nursing License to practice as a Registered Nurse (RN) in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
• Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association (AHA) throughout employment

Experience:

• Three (3) years of clinical nursing experience performing direct patient care with at least 2 years in an Inpatient setting on a medical-surgical unit, PACU, or higher acuity Inpatient unit (ICU, Step-Down, Telemetry, etc.) or home health (direct care) {clinical experience qualification may be determined by hiring manager/director.}
• Demonstrate knowledge of case management, purchased referred care and utilization review
• Demonstrate knowledge of electronic health record systems.

Other Skills and Abilities:

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:

• Positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable; reports to work as scheduled without excessive absences
• Effective verbal & written communication skills
• Team management focus promoting a positive and pro-active approach to problem resolution
• Experience in hospital-based utilization review
• Proficient or experienced with clinical criteria sets for Miliman Care Guidelines(MCG)
• Completion of and receiving above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewers and TCRHCC that the applicant can perform the essential functions of the job
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC.

MENTAL AND PHYSICAL EFFORT

The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical:

This position requires an individual of high energy who can maintain a long and flexible schedule to meet the management requirements. The physical requirements include; sitting at a desk for long periods of time, long periods of sitting in meetings; frequent sitting for intense work on a personal computer, frequent walking to interact with staff within the facility, frequent bending, kneeling, crouching, twisting, maintaining balance and reaching. Must be able to hear, speak and comprehend over the telephone and in person with others. Must have ability to lift, push and pull up to 50lbs frequently. Sensory requirements for position include prolonged ability for far, near, and color vision, depth perception, seeing fine details, hearing normal speech, telephone use and ability to frequently hear overhead pages. Must have ability of both hand manipulation in simple and firm grasping, fine manipulation, and use of keyboard.

Mental:

Uses independent judgment and analytical skills to make decisions that impact operations, finances, and customer service within the organization. The incumbent must have the ability to perform in structured and unstructured environments and possess a keen attention to detail and propose practices/mechanisms to enhance customer satisfaction. Must have ability to continually concentrate, handle a high degree of flexibility, handle multiple priorities in stressful situation, demonstrate high degree of patience, adapt to shift work, work in areas that are close in crowded, frequently cope with high levels of stress, make decisions under high pressure, work alone, and occasionally cope with anger/fear/hostility of others in a calm way and manage altercations.

Environmental:

May frequently be exposed to chemical agents, extremes in temperature of humidity, occasional exposure to infectious diseases, dust, fumes, gases, hazardous or moving equipment, and loud noises.

Responsibilities

ESSENTIAL FUNCTIONS

• Adheres to most current ACMA Case Management Standards of Practice and Scope of Services

• Adheres to ANA Nursing Scope and Standards of Practice

• Adheres to most current ANA The Code of Ethics for Nurses

• Coordination of service specific assessments, service planning and enrollment.

• Works with all facets of the Case Management continuum, i.e., social support, alternate resources, community referrals, discharge planning, Nursing Home/Skilled Nursing Placement and resource utilization.

• Comprehensive and client centered service planning and coordination

• Works proactively with the established RN Case Managers/ Social Workers of TCRHCC as a team member for care coordination of the patient populations served by TCRHCC.

• Consistent and on-going case consultation with all direct service providers.

• Developing and maintaining internal and external resource relationships.

• Promote patient advocacy

• Promote quality of care

• Promote cost effective medical outcomes

• Promote appropriate admission status

• Provide continuity of care between utilization management and care coordinators

• Commits to professional development towards becoming an expert in utilization management including but not limited to:

• Knowing Medicare rules and regulations related to utilization

• Knowing payor policies related to utilization management

• Knowing TCRHCC 638 policies related to utilization management.

• Keeping abreast of current changes affecting utilization management as applicable.

• Collaborates with attending physician if ambiguous documentation pertaining to patient status placement requires clarification.

• Utilizes electronic utilization management database for documentation of interventions and communications (MCG Guidelines, Careport and Allscripts)

• Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise

• Collaborates with payor utilization management liaisons and medical directors as applicable.

• Uses clinical and analytical skills to review and interpret diagnostic test results to determine appropriateness of patient's level of care.

• Assists with the development of department reports, policy/procedures manuals, and program objectives

• Conduct system and procedural efficiency evaluation to determine progress, performance, and conformity with program requirements.

• Will provide a consistent and on-going collaboration through communication with service providers.

• Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record.

• Improves the overall quality and completeness of clinical documentation by performing admission/continued stay clinical reviews using clinical enhancement guidelines for selected patient populations.

• Reviews clinical issues as needed with the coding staff to assign a working DRG to reflect any changes in patient status and procedures/treatments and confers with the physician to finalize diagnoses.

• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and clarified with the physician have been recorded in the patient's chart.

• Participates in review and analysis of monthly data relating to clinical quality documentation and insurance medical necessity criteria.

• Ensure proper PPE is worn at all times while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.

• Completes all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updated)

• Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction.

• Performs other duties as assigned.