RN Utilization Review

Relief, Variable Pay range: $48.30 - $72.45 ST. CHARLES HEALTH SYSTEM JOB DESCRIPTION TITLE:                                      RN Utilization Management REPORTS TO POSITION:         Manager- Utilization Management DEPARTMENT:                        Utilization Management DATE LAST REVIEWED:             November 2024 OUR VISION:                           Creating America’s healthiest community, together OUR MISSION:                         In the spirit of love and compassion, better health, better care, better value OUR VALUES:                         Accountability, Caring and Teamwork DEPARTMENTAL SUMMARY: The Utilization Management (UM) Department promotes and provides a centralized, collaborative multi-disciplinary approach to utilization management across St. Charles Health System (SCHS). The UM Department supports physicians and clinical staff in identifying and improving care processes and systems for establishing and ensuring medical necessity, appropriate utilization of services, supporting denial avoidance and recovery and compliance with all local, state and federal regulations. POSITION OVERVIEW The Utilization Management Registered Nurse (RN) has well-developed knowledge and skills in areas of utilization management, medical necessity and patient status determination. The UM RN supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. The UM RN is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated and reported. When screening criteria does not align with the physician order or a status conflict is indicated, the UM RN is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. The UM RN is responsible for denial avoidance strategies including concurrent payer communications to resolve status disputes. Additionally, the UM RN monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences and designing and implementing process improvement projects as needed. This position does not directly manage any other caregivers. ESSENTIAL FUNCTIONS AND DUTIES: Acts as an interdisciplinary team member within the UM Department, may be responsible for providing cross coverage for roles and responsibilities of other UM team members to back-fill during earned time off and/or during backlogs due to peak volumes.  Performs pre-admission status recommendation review for multiple care settings as assigned (i.e. Emergency Department, Direct Admission/Transfer, and/or elective procedure), to communicate with providers status guidance based on available information. Ensures appropriate patient status upon admission and manages patient status conversions, as appropriate. Ensures completion of admission medical necessity reviews within 24 hours of admission. Completes concurrent inpatient medical necessity reviews at a minimum of every three (3) days unless otherwise specified by payor. Completes Observation medical necessity reviews at a minimum of every 12 hours (twice daily). Completes Medicare extended stay reviews, as appropriate. Assigns an initial working DRG & GMLOS upon completion of initial medical necessity review for IP admission and enters in EMR. Completes discharge reviews and ensures completeness of all prior medical necessity reviews and authorizations; escalates concerns, as appropriate. Identifies and escalates all 1MN and 2MN Medicare IP stays. Collaborates with Care Management (CM) team, as appropriate (i.e. extended observation stays, patients no longer meeting medical necessity, status changes). Collaborates with physicians, as appropriate (i.e. to address issues concerning medical necessity, status orders, appropriate level of care, peer-to-peer involvement, etc.). Collaborates with payors, as appropriate (i.e. discuss status, changes in LOC, changes in pre-authorizations warranting reauthorization, etc.). Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM), as appropriate. Escalates Medical Necessity (patient status / LOC) concerns and other UM concerns to Physician Advisor or designated leader, as appropriate. Assists with discharge appeal process, as appropriate. Provides timely and continual coverage of assigned work area in order to ensure all accounts are complete. Assists in the identification of Avoidable Days and communicates information with CM, as appropriate. Complies with all documentation requirements. Follows up on action items prior to the end of shift. Maintains a working knowledge of payor contracts and regulatory requirements and UM specific changes (i.e. changes in authorizations, payor contracts, CMS, regulatory requirements). Completes all tasks within department guidelines. Adheres to the policies, procedures, rules, regulations and laws of the hospital and federal and state governing bodies. Provides support regarding Medicare documentation requirements. Obtains verbal admission orders from physicians and monitors for authorization by the physician. Participates in the delivery of regulatory forms to patients when appropriate. Communicates with insurance companies regarding the medical necessity of the admission and provides clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays.  Actively participates in clinical performance improvement activities. Assists in the collection and reporting of resource and financial indicators including LOS, cost per case, avoidable days, re