Registered Nurse (RN) - Utilization Review

Overview

Works with physicians and multidisciplinary team members to develop a plan of care for assigned patients. Ensures patient is progressing towards desired outcomes by monitoring care through assessments and/or patient records. Identifies and resolves barriers that hinder effective patient care. Actively involved in discharge planning process.

 

*Strong candidate identified

Responsibilities

Works with Medical Director and appropriate physician(s) to establish Dartmouth-Hitchcock (D-H) ambulatory and inpatient procedure list, updates and maintains list.

Reviews reservation forms and the log of emergent and urgent admissions daily.

Identifies areas that require intervention and education around the use of definitions.

Reviews “one day stays” to assess appropriate use of level of care (LOC) determinations.

Works with individual physicians and office staff when they are experiencing discrepancies with pre-certifications.

Assumes responsibility for the oversight of inpatient denials, including, but not limited to, reviewing denial letters, collaborating with the Medical Director and appropriate physicians to determine the decision to appeal or accept, assisting in the response to Health Plan, etc.

Develops and implements communication strategies to keep clinicians and staff informed of changes and current practice.

Works closely with others to transition level of care determinations.

Provides information to departmental leadership that reflects trends and practices that may need organization, intervention, and change.

Collaborates with Health Plans to understand their definitions, articulates the definitions of D-H, and assists in the development of strategies for resolution of differences.

Benchmarks with other facilities concerning admission and denial experience and policies.

Performs other duties as required or assigned.

Qualifications

• Graduate from an accredited Nursing Program required.
• Bachelor of Science Degree in Nursing (BSN) with 3 years of experience.
• Masters of Science Degree in Nursing (MSN) preferred.
• Strong leadership, communication and computer skills desired.

Required Licensure/Certifications

• Licensed Registered nurse with NH eligibility