Utilization Review Nurse - Case Management - Part-Time - Days

PURPOSE OF JOB: To review each admission for appropriate assignment of level of care based upon clinical guidelines as well as to review documentation for continued stays daily and provide clinical information including assessments and outcomes for all payers and all levels of care as required by the payer. Work with physician advisor to better manage denials and downgrades.

ESSENTIAL FUNCTIONS:

Perform effective application of utilization criteria and methodologies and be accountable for established performance standards over a single episode of care.

Maintain communication and submit all clinical data to payers according to contract requirements (telephonically, fax, XSOLIS).

Document all activities/outcomes in ALLSCRIPTS/Meditech/XSOLIS in a timely manner.

Collaborate with physician advisor on individual denials/appeals to ensure completion and closure of utilization management process per episode. Collaborate with Admissions to provide and attain precertification/authorization.

Participate in the collection of information regarding quality improvement activities, risk management issues and department audits.

Job Qualifications:

QUALIFICATIONS:

Education:

Registered Nurse: must have a current license in Pennsylvania from the Commonwealth of Pennsylvania, Department of State Bureau of Professional and Occupational Affairs. Bachelor degree preferred.

Experience:

Registered Nurse: a minimum of five or more years of acute care clinical nursing. Recent experience in a hospital, insurance company, or independent review company in utilization, quality review, homecare or case management.

Other Skills:

General Skills All Disciplines: Excellent verbal and written communication skills. Strong organizational and prioritizing skills. Thorough understanding of managed care systems and utilization review criteria. Knowledge of community resources. Demonstrated leadership abilities. Experience in the use of information systems.