RN - Utilization Review; Senior Care

Description

 Job Title: RN - Utilization Review Nurse; Senior Care 

Supervised by: RN Nurse Director, Case Management

Job Summary: 

The Behavioral Health Utilization Review (UR) Nurse ensures appropriate utilization of inpatient psychiatric services for geriatric patients through medical necessity review, level-of-care validation, documentation compliance, and denial prevention activities.

This role supports compliance with: 42 CFR §482.30 (Utilization Review); 42 CFS §482.60 (Psychiatric Services Conditions of Participation); Medicare Inpatient Psychiatric Facility (IPF); Prospective Payment System; Arkansas Nurse Practice Act

The UR Nurse applies approved behavioral health criteria to ensure medical necessity, appropriate length of stay, and regulatory compliance in the acute geriatric behavioral health setting.

Scope of Role by Licensure:

• Perform independent clinical review and determination using approved criteria.
• Recommend level-of-care adjustments.
• Conduct peer discussions with providers.
• Participate in denial peer-to-peer preparation.
• Serve as clinical liaison to Physician Advisor.

Demonstrates Competency in the Following Areas:

• Reviews psychiatric admissions for: Acute behavioral instability; risk of harm to self or others; severe mood disturbance; psychosis; medication stabilization needs; and dementia with behavioral disturbance requiring inpatient care.
• Validates documentation of: psychiatric evaluation within required timeframe; admission certification; individualized treatment plan; and active treatment documentation.
• Conducts ongoing review to confirm: continued acute psychiatric criteria; active treatment progression; medication adjustments and response; and multidisciplinary plan updates.
• Monitors length of stay (LOS) against benchmarks.
• Identifies avoidable days and discharge barriers (placement, guardianship, SNF acceptance).
• Ensures documentation reflects acuity beyond custodial care in cases involving: major neurocognitive disorder with behavioral disturbance; delirium vs psychiatric decompensation; late-life depression; bipolar disorder; psychosis; polypharmacy complications and behavioral symptoms requiring structured milieu and medication adjustment.
• Identifies documentation gaps impacting severity-of-illness and intensity-of-service.
• Collaborates with providers to strengthen documentation.
• Assists with appeal preparation.
• Tracks denial trends specific to psychiatric services.
• Ensures compliance with: Active treatment requirements; 7-day treatment plan reviews; recertification requirements; seclusion and restraint documentation standards; and IPF PPS documentation standards.
• Participates in UR Committee and Behavioral Health QAPI processes.
• Tracks and reports: Average Length of Stay (ALOS); denial rate; avoidable patient days; 30-day readmissions; transfer-out rates; and certification compliance rate.
• Prepare utilization reports for: Behavioral Health Program Director; Executive Administration team; and Governing Board.

SUPERVISION & ESCALATION STRUCTURE

• Reports to RN Nurse Director – Case Management.
• Clinical oversight provided by RN leadership and Physician Advisor.
• Final authority for disputed medical necessity determinations resides with Physician Advisor and UR Committee.

PERFORMANCE METRICS (KPIs)

• Psychiatric denial rate
• Average Length of Stay vs benchmark
• Avoidable days
• Certification compliance
• Appeal overturn rate
• Documentation improvement trends

Professional Requirements

•  Adheres to dress code, appearance is neat and clean. 
• Completes annual education requirements. 
• Maintains regulatory requirements. 
• Maintains patient confidentiality at all times. 
• Reports to work on time and as scheduled, completes work within designated time. 
• Wears identification while on duty. 
• Completes in-services and site audits, returning in timely fashion. 
• Attends annual review and performs in-services.
• Ensures compliance with policies and procedures regarding department operations, fire safety, emergency management and infection prevention and control.
• Actively participate in performance improvement and continuous quality improvement (CQI) activities.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics and goals of the organization.