Registered Nurse, Utilization Coordinator - Hybrid

We are recruiting for a motivated Registered Nurse, Utilization Coordinator - Hybrid to join our team!

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Department

Hospital Care Mgmt

Job Summary

Under general supervision, the RN Utilization Review Coordinator will facilitate the appropriate status and level of care. This includes all commercial insurance, Medicare, Medicaid and self-pay. These will be reviewed on a cadence defined in the specific workflow. All Reviews will be done to ensure compliance with all state, federal and third-party payors. They will communicate daily and as needed to the RN Care Coordinator, Clinical Social Worker and healthcare teams.


Essential Functions:

• Status and Level of Care Management
  • Manages observation status patients to determine appropriateness for discharge or conversion to inpatient admission using approved medical necessity criteria continually throughout the observation stay
  • Conducts medical necessity reviews on all inpatient admissions, transfers and continued stay patients using approved medical necessity criteria daily
  • Initiates Condition Code 44 process when applicable
  • Works with the Clinical Documentation Improvement Specialists and physicians to identify opportunities to improve the accuracy of the documentation as well as identify the working MSDRG and associated geometric mean length of stay
  • Conducts proactive medical necessity review of cases being referred from the Emergency Room, PACU, transfers and direct admissions from physician offices to ensure appropriate status and level of care placement , as assigned
  • Uses the criteria software application to document results of criteria application according to the documentation policy, i.e. MCG criteria application, length of stay assignments and variance documentation, etc.
  • Initiates Physician Advisor referrals for any cases not meeting criteria for the level of care
  • Ensures compliance with all state, federal and payor medical necessity and certification requirements
  (40%)
• Utilization Review for Insurance Companies
  • Documents clinical information as required for insurance company certification according to required payor timeframe standards
  • Works collaboratively with the Clerical Support Staff to ensure all insurance reviews are received by the insurance company and a disposition response is received
  • Documents all insurance certification activities in the assigned locations according to the department documentation standards
  (40%)
• Compliance
  • Ensures compliance with all applicable state and federal regulatory requirements as well as the insurance company rules such as Patient Choice, Important Message from Medicare #2, Condition Code 44, insurance certification processes, etc.
  • Maintains compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines
  • Protects Patient Rights as they pertain to the ethical and legal issues of confidentiality during the case management process
  (20%)

Education:

• Associate's Degree Completion of a nursing education program that satisfied the licensing requirements of the Colorado State Board of Nursing for Registered Nurses. Required

Work Experience:

• 1-3 years years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required. Required

Licenses:

• RN-Registered Nurse - DORA - Department of Regulatory Agencies Required

Knowledge, Skills and Abilities:

• Bilingual in English/Spanish preferred.
• Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment.
• Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times. Strong customer service orientation and aptitude.
• Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
• Ability to communicate verbally and in writing complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Microsoft Office Suite required.
• Experience with windows-based computer programs and ability to use computer for data analysis