RN Utilization Management Concurrent Review

Hampton, Virginia

Overview

Responsible for the judicious management of health system resources through advocacy for both the patient and the organization. Provides concurrent medical necessity reviews for all patients hospitalized within the organization in accordance with national guidelines and standards of excellence, in accordance with the UM Plan established by the organization, facility goals, and strategic plans. Communicates with payers to ensure authorization for services is obtained for appropriate reimbursement.

What You Will Do

Recognizes and demonstrates shared accountability, both at the patient and the team levels. Contributes to decision-making and decision support as a member of the interdisciplinary team. Provides continued stay medical necessity reviews and communicates the findings to physicians and Care Management team members based upon a thorough medical record review and knowledge of federal and evidence-based guidelines, including CMS Conditions of Participation.

Aligns practice with organization’s mission and vision. Advances the application of research and evidence-based practices through the expert use of MCG national guidelines when completing concurrent medical necessity assigning levels of care to admitted patients. Communicates effectively and professionally regarding modality. Provides education regarding utilization management to patients, families, and other members of the care team as needed.

Maintains current knowledge of health care economics, trends, and reimbursement methodologies, and applies this knowledge to daily practice. Stays current via continuing education, MCG Interrater Reliability, and ACMA Compass modules.

Respects and incorporates patients’ goals of care and treatment preferences while respecting available resources. Builds and maintains relationships that foster trust and confidence. Engages with physician leaders to provide education and promote optimal patient care. Routinely collaborates with members of the interdisciplinary team, physician advisors, and facility leadership. Ensures timely notification and communication of pertinent clinical data to support admission, clinical condition, and continued stay authorization to payers as required.

Advocates on behalf of patients / families / caregivers for service access or creation and for protection of the patient’s health, well-being, safety, and rights. Promotes and engages in culturally competent care. Partners with providers and payers to ensure the patient can access their full benefits. Balances resources with patient preferences. Advocates for the organization regarding compliance with the administration of required notices when medical necessity does not exist and ensures the patient / family is in complete understanding.

Manages cost of care with the benefits of patient safety, clinical quality, risk, and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes. Informs the interdisciplinary team of the economic impact of treatment options. Proactively prevents medical necessity denials by providing education to physicians, staff, and patients, interfacing with payers and documenting relevant information. Applies knowledge of contractual arrangements and payment models to daily practice.

Embraces and incorporates innovation and technology to improve collaboration and patient outcomes. Ensures compliance with organizational policy and regulatory requirements to securely transmit patient information and protect their health information. Utilizes established processes for secondary review when warranted.

Qualifications

Education

Bachelors Degree, Nursing (Preferred)

Program Graduate, Professional Nursing (Required)

Experience

3-4 years Clinical nursing experience (Required)

Skills And Abilities

Excellent verbal and written communication skills

Excellent interpersonal skills

Excellent organizational skills and attention to detail

Ability to act with integrity, professionalism, and confidentiality

Proficiency with computer systems required to perform job

Licenses and Certifications

Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) (Required)

Certified Case Manager (CCM) - Commission for Case Manager Certification (Preferred) or

Accredited Case Manager (ACM) - American Case Management Association (ACMA) (Preferred)

Other Requirements

Call Rotation

To learn more about being a team member with Riverside Health System visit us at https : / / www.riversideonline.com / careers .