Utilization Review Nurse (RN)

Scope:

Seeking a RN with a minimum of 2 years of experience in working as a utilization review nurse in an acute care setting.  Must be experienced working with Epic.  Must be experienced with reviewing payor policies for medical necessity criteria regarding observation and inpatient. Preferably experienced with InterQual, but willing to train for the right candidate.  Must be able to conduct reviews on minimum of 20 cases per shift, post training and 4 week ramp up.  Client is on Pacific time must be able to work most of the shift between 8am and 4pm PST.  

Job Summary
The Utilization Review RN monitors utilization practices from preadmission to discharge to assure cost-effective utilization of resources, quality
patient care, and compliance with regulatory requirements. This role is responsible for reviewing the medical record to ensure documentation
demonstrates medical necessity according to regulatory guidelines. The Utilization Review RN will actively manage and communicate with key
members of the care team to secure accurate documentation and admission status.
Job Requirements
2 years’ progressive nursing experience in an acute care setting preferably within discharge, utilization and/or case management or equivalent
combination of education and/or experience.
Required:
*RN: Registered Nurse Licensed by Oregon State Board of Nursing
Preferred:
*Bachelor's degree in Nursing
*CCM: Certified Case Manager
*ACM: Accredited Case Manager
Additional Position Specific Requirements
Working Conditions
Essential:
* Phy-Sit comfortable position,frequent opportunity to move
* Enviro-Indoor-Comfortable area
* Hazards-Only unplanned exposure to blood, body fluids
* HIPAA-Pay-View or read only minimum for work assignment
* HIPAA-Treat-Originate, view, change nec for work assignment
* HIPAA-Ops-View or read only minimum for work assignment
Responsibilities
1 Communication. Accepts responsibility for receiving and disseminating information related to system, departmental and patient processes.
1.1 Participates in department and inter-departmental meetings. Consistently uses both camera and audio function during remote meetings as
necessary
1.2 Takes responsibility for reviewing staff meeting minutes when unable to attend scheduled meetings.
1.3 Uses email, Microsoft Teams and other forms of communication appropriately and as directed by Asante policy.
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1.3 Uses email, Microsoft Teams and other forms of communication appropriately and as directed by Asante policy.
1.4 Escalates issues to supervisor appropriately per department guidelines.
2 Data Collection. Participates in data collection activities to support departmental programs and services.
2.1 Keep accurate statistics of interventions as related to team productivity.
2.2 May need to collect and analyze surgical case data for monthly submission.
2.3 Works with team lead/supervisor to ensure accurate reporting related to team productivity and physician practice trends.
2.4 Maintains electronic accounting of cases worked by entering detailed notes correctly into EPIC.
2.5 May need to keep accurate statistics on review outcomes to identify problem areas along continuum that need addressing and to assist in
future physician contract negotiations.
3 Performance Improvement and collaboration. Monitors and reports on patient outcomes and actively works with other members of the
interdisciplinary team to facilitate improved delivery of cost-effective services.
3.1 Actively participates on interdepartmental or intradepartmental process improvement activities.
3.2 Demonstrates flexibility and willingness to adjust workload or duties in response to unexpected changes in work volume, emergencies, staffing
and scheduling.
3.3 Provides ongoing education for physicians and nursing staff in regulatory mandates as they apply to utilization management practices.
3.4 May need to identify trends and areas of opportunity for provider specific education.
3.5 May need to investigate department circumstances that create barriers to having a complete medical record pre-operatively.
4 Professional Development. Accepts responsibility for professional self-development.
4.1 Demonstrates excellence in clinical practice through proactive, self-directive behavior using creative thinking skills..
4.2 Strives to improve practice though participation in educational activities, staff meetings and unit committees.
4.3 Functions as a positive role model and recognizes and utilizes the expertise of colleagues to create a cohesive work team.
4.4 Handles issues using assertive communication skills and takes action based on constructive performance feedback seeking guidance