Employee is expected to cheerfully and enthusiastically carry out tasks and responsibilities of the job, including but not limited to, high quality professional patient care, thorough and accurate documentation, a willingness to work closely with physicians, administrators, coworkers, and supervisors. Prompt assistance to other units/ departments is expected as well as prompt assistance within the employee’s own unit/ department. By following the guidelines outlined in this job description, high quality patient care will be assured, and the continued success of Curative.

Essential Duties And Responsibilities

Interacts with providers, facilities, and their staff regarding pre-certifications, concurrent review, discharge planning, retrospective review, redirections, denials, appeals, and complaints
Formulates and promotes continuity of care ensuring appropriate medical treatments, processes and utilization of resources
Provides concurrent review by assessing the medical necessity and the appropriateness of acute inpatient, SNF, and custodial care in order to justify the continued level of care and identification of avoidable days due to barriers to care
Provides discharge planning and continuity of care activities including but not limited to home care, DME coordination, follow up with primary care and/or specialist
Collaborates with the Medical director of Curative, Medical Management Manager and Director of Case Management to develop and implement ways to decrease hospital stays in a medically safe and responsible manner in incorporating criteria based concurrent review techniques, within the parameters of the patient’s health plan
Reports monthly avoidable days, significant interventions and quality triggers
Work in close coordination with home care delivery systems, outpatient providers and other community agencies to assure follow through of the Utilization Management effort
Communicates service delivery problems to Manager as identified through the Utilization Management System
Receives and reviews written and verbal requests for patient services
Reviews all requests for appropriateness according to established guidelines and coordinated review with plan benefit guidelines
Receives and reviews requests for services and approves or refers requests for Medical Director review when criteria are not met
Enters authorizations/pre-certifications into the Utilization Management System
Communicates with Claims and Customer Services on the status of requested services through the Utilization Management System
Accurately codes appropriate diagnosis and procedures into the Utilization Management System according to ICD.10 and CPT guidelines
Communicates outcome of referral reviews to physician and/or other office staff and provides authorization numbers
Participates in special projects as required
Researches complex cases as needed under the direction of the Manager or Medical Director
This position assumes and performs other duties as assigned.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential Functions

At least four years of clinical experience in hospital nursing such as Critical Care/ER/Med Surg/Home Health.
One to two years of utilization/case management (managed care preferred).
One to two years of concurrent review or retrospective review with an emphasis on discharge planning.
Current knowledge of services provided across the continuum of care that involve multiple systems addressing the ongoing needs of the patient
Knowledge of discharge planning Familiarity with community agencies and with how to make appropriate referrals to review criteria
Knowledge of different hospital reimbursement methodologies and concurrent review criteria
Excellent verbal and written communication skills
Computer skills
Ability to identify ways to decrease hospital days in a medically safe and responsible manner

EDUCATION And/or EXPERIENCE

Associate's degree (A. A.) or equivalent from two-year college or technical school in Professional Nursing
Bachelor's degree (B. A.) from four-year college or university in Professional Nursing (preferred)

CERTIFICATES, LICENSES, REGISTRATIONS

Texas Registered Nurse licensure

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable Individuals With Disabilities To Perform The Essential Functions.

❑ While performing the duties of this Job, the employee is regularly required to sit; use hands to

handle or feel; talk; and hear.

❑ The employee is frequently required to reach with hands and arms.

❑ The employee is occasionally required to stand; walk and stoop, kneel, crouch, or crawl.

❑ The employee may regularly be required to lift and/or move up to: _10_ LBS

Curative jobs

Utilization Review Nurse - RN

Utilization Review Nurse - RN