Employment Type:

Full time

Shift:

Day Shift

Description:

Utilization Review- RN Reviewer- Regional Coverage for Loyola, Gottlieb and MacNeal Hospitals.

**Position will be responsible for Gottlieb Memorial Hospital, Loyola University Medical Center, and MacNeal Hospital. Office location is Loyola campus. Position is hybrid, must reside in Illinois.

The Regional Utilization Review Documentation Specialist nurse works with the multidisciplinary team including physicians, staff and payers to ensure patient's progress along the continuum of care in an efficient and cost-effective manner that ensures quality outcomes. They utilize established guidelines to support appropriate level of care throughout hospitalization. They serve as a liaison between the hospital and external payers on issues related to severity of illness and intensity of service for patients to ensure appropriate and timely utilization of hospital services. This position will reflect a regional coverage. The position includes but not limited to basic UR job duties such as level of care determination, clinical submission to payers, timely following/securing of auth payer status, timely discharge notification, monitoring status of procedural cases and submitting/monitoring post acute authorization status.

Admission and Concurrent Case Review:

• Uses approved criteria for admission and continued stay reviews to ensure appropriate setting and timely implementation of plan of care.

• Monitors patient's progress across the continuum and intervenes as necessary to ensure quality services that are efficient and cost effective.

• Collaborates with admitting physician regarding appropriate level of care/status determination.

• Consults with Physician Advisor and administrative leadership as necessary for those patients not meeting medical necessary services for acute care.

• Knowledgeable of Medicare, Medicaid and non-governmental payer regulations for patient care requirements.

• Responds to requested insurance reviews based on contractual obligations.

• Actively manages concurrent denials.

• Reports data per request of the appropriate leadership for information and resolution, which may include risk management, epidemiology, payer requirements, and performance improvement departments.

Regulatory and Contractual Compliance:

• Demonstrates service excellence by providing complete clinical information to government and non-governmental review organizations following HIPAA guidelines.

• Identify and document appropriate necessary changes in level of care.

• Partners with Care Management for Medicare patients disputing their discharge.

• Delivery of Detailed Notice of Discharge and transmission of medical records to the QIO within required timeframes.

• Partners with Care Management for delivery of any regulatory documentation.

• Documents all pertinent communication regarding certification in clinical database.

• Timely submission of all initial, concurrent and discharge reviews.

• Serves as a resource to the healthcare team regarding utilization standards and potential alternatives to acute care hospitalization.

• Evaluate hospitalized patients to make sure they are receiving services in the most appropriate and cost - effective setting in collaboration with attending physicians. 

• Actively participates in the Utilization Management committee.

• Additional responsibilities as needed.

We offer our employees:

• Benefits from Day One

• Competitive compensation

• Career Development

• Tuition Reimbursement

• On Site Fitness Center

• Educational Stipend

• Referral rewards

Our Promise to You:

Joining Loyola Medicine is being a part of an organization that treats the human spirit in our patients and in our colleagues.  We are a part of a community which believes in giving back to those we serve.

We seek colleagues with:

• Bachelor's degree in Nursing; Master's degree preferred.

• 3-5 years of previous job-related experience required.

• 6-10 years of previous job-related experience preferred.

• Strong clinical background is necessary.

• Clinical experience in medicine, surgery, critical care, telemetry, or ED is required.

• Recent UR experience is preferred.

• Excellent organizational, time management,typing and communication skills are necess