Utilization Review Nurse
: Job Details :

JOB SUMMARY Under the direction and supervision of the Director of Health Information Management, the Utilization Management Coordinator is responsible for providing utilization services to meet the needs of patients and hospital staff and for performing related duties; and for participating in a utilization management program in compliance with federal and state regulations. POSITION QUALIFICATIONS/REQUIREMENTS Education •Graduate of accredited school of nursing Licensure and Certifications •Current RN/LPN Licensure in the state of WV Experience Minimum of three (3) years' experience in healthcare (e.g. clinical care, utilization review, case management, nursing or related field). •Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting. •Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers and third party payers. POSITION RESPONSIBILITIES This Job Description is not to be construed as a complete listing of the assignments that may be given to any employee, nor are such assignments restricted to those precisely listed in the description. 1. Perform case screening on all inpatient and observation patients utilizing Interqual criteria. 2. Conducts the initial admission review within the first 48-72 hours following admission and either faxing or calling third party payers for certification of the stay (when required by the third party payer) within said time frame. 3. Conducts continued stay review at least every 72 hours for Medicare patients and/or as required by third party payers. 4. Initiates a plan for the patient after careful analysis of all data and with input from all disciplines involved in the patient's care. 5. Function as a resource for physicians, nursing and ancillary staff concerning estimated length of stay, avoidable hospital days and utilization of services. 6. Ensures commitment to standards of quality patient care by participating in the Integrated Quality Management Committee. 7. Coordinates the weekly multidisciplinary team conferences. 8. Monitors and facilitates appropriate utilization of resources. Track and report trends of inappropriate resource utilization to administration and the IQM Committee. 9. Maintains current working knowledge of third party payer guidelines and review criteria. 10. Assist and teaches other departments how to identify opportunities to streamline care, avoid duplication and prevent delays in service. 11. Update physicians on documentation that is needed to justify the admission, treatment, length of stay and accuracy of diagnosis. PHYSICAL DEMANDS/WORKING CONDITIONS Physical •Work is primarily sedentary. •Employee generally sits to do the work. •There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. •Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices. Work Schedule: Days Status: 75 hrs per pay Location: Stonewall Jackson Memorial Hospital Location of Job: WV:Weston:Stonewall Jackson Memorial Hospital Talent Acquisition Specialist: Guy S. Stewart ...@vandaliahealth.org