University Of Utah Medical Group Murray , UT 84107
As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission. EO/AA
This position is responsible for maintaining the financial integrity of both the patient and the organization through the provision of quality based patient care focusing on the medical necessity and efficiency of the delivery of such care; achieved via managing the cost of care while providing timely and accurate information to third party payers and medical care team.
Applies approved utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review.
Communication to third-party payers for initial and concurrent clinical review.
Reviews patient chart to ensure patient continues to meet medical necessity.
Documentation of all actions and information shared with care team members or third-party payer.
Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay.
Discusses with physicians the appropriateness of resource utilization.
Tracks length of stay (LOS) and resource utilization to identify at risk patients.
Refers to UR committee any case that surpasses expected LOS, expected cost, or over/underutilization of resources.
Performs verbal/fax clinical review with payer as determined by nursing judgment and/or collaboration with the payer per university contractual obligation.
Participant in UR Committee as needed.
Collects data on variances in LOS, avoidable days, costs/barriers to discharge/transition and denied days.
Prepares appeals on denied cases when appropriate.
Knowledge / Skills / Abilities
Ability to perform the essential functions of the job as outlined above.
Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills.
Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria.
The ability to demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.
Ability to work autonomously and as a team member.
Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 30 days of hire under the interstate compact.
Additional license requirements as determined by the hiring department.Qualifications (Preferred)Preferred
Basic Life Support Health Care Provider card.
Proficiency in application of InterQual Criteria, knowledge of ICD-9, DRG's and CPT Codes.
Utilization Review Certifcation designation.
Knowledge of CMS Regulations.
Working Conditions and Physical Demands
Employee must be able to meet the following requirements with or without an accommodation.
Physical RequirementsListening, Sitting, Standing