ST. CHARLES HEALTH SYSTEM
RN Utilization Management
Manager, Utilization Review
September 12, 2017
Creating America’s healthiest community, together
the spirit of love and compassion, better health, better care,
Accountability, Caring and Teamwork
DEPARTMENTAL SUMMARY: The Utilization Review Department
provides many services to our multi-hospital organization
including: Support to physicians and clinical staff in determining
whether all aspects of a patient’s care, at every level is
medically necessary and appropriately delivered. The Utilization
Review department also acts to ensure compliance with the Medicare
Conditions of Participation and capture of appropriate
reimbursement for the health system.
POSITION OVERVIEW Under the supervision of the
Manager/Director, Utilization Review, the Utilization
Management RN completes clinical reviews of hospital
admissions for medical necessity, utilizing InterQual criteria, so
that revenue is fully and accurately captured for hospital
stays. Assures conformity to the federal and state government
health care program requirements, the internal hospital utilization
review process, and any third party payor utilization review
processes or managed care process. Works closely with
physicians, nursing staff, insurance companies, patient
registration, and patient financial services to accurately document
medical necessity and admitting status for each admission. This
position does not directly manage any other caregivers.
ESSENTIAL FUNCTIONS AND DUTIES:
Performs clinical chart reviews for appropriateness and medical
necessity of admissions, continued stays, and supportive services
to promote quality care and full and accurate capture of
Following completion of clinical reviews for medical necessity
of hospital stays, refers to second level review when
Communicates with the physicians, as needed to address issues of
medical necessity and appropriate level of care -- and may provide
support regarding Medicare documentation requirements. May obtain
verbal admission orders from physicians and monitor for
authorization by the physician. May participate in the delivery of
regulatory forms to patients when appropriate.
Communicates with insurance companies regarding the medical
necessity of the admission and provides clinical documentation and
reviews to insurance companies as requested for purposes of ongoing
authorization of hospital stays.
Keeps patient registration and patient financial services
informed of any changes in admission status, working towards
accurate capture of admission status prior to the time the initial
billing is sent.
Continually assesses clinical services for appropriateness for
Notifies case management of potential problematic cases.
Serves as a resource and actively provides education to
physicians on inpatient and observation medical necessity
Participates with the Utilization Review Committee.
Quality of care issues are identified and reported through the
EMS system or immediately if indicated, to risk management.
Has primary responsibility when medical necessity denials are
received to complete an additional review and prepare and
coordinate medical necessity appeals. Works closely with
compliance auditor to provide clinical reviews and appeals for RAC,
CERT, and MAC denials and audits.
Serves as a clinical resource for non-nursing members of the
Utilization Management department.
Participates in clinical care conferencing.
Documents actions taken in the patient financial record and
performs clinical reviews using commercial review
Participates in tracking of departmental quality measures by
entering data in the UM database for compilation.
Supports the vision, mission and values of the organization in
Supports Value Improvement Practice (VIP- Lean) principles of
continuous improvement with energy and enthusiasm, functioning as a
champion of change.
Provides and maintains a safe environment for caregivers,
patients and guests.
Conducts all activities with the highest standards of
professionalism and confidentiality. Complies with all
applicable laws, regulations, policies and procedures, supporting
the organization’s corporate integrity efforts by acting in an
ethical and appropriate manner, reporting known or suspected
violation of applicable rules, and cooperating fully with all
organizational investigations and proceedings.
Delivers customer service and/or patient care in a manner that
promotes goodwill, is timely, efficient and accurate.
May perform additional duties of similar complexity within the
organization, as required or assigned.
Required: Graduate of an accredited school of
Required: Current Oregon RN license
Required: Minimum 3 years of combined hospital
related Utilization Review experience
PERSONAL PROTECTIVE EQUIPMENT:
Must be able to wear appropriate Personal Protective Equipment
(PPE) required to perform the job safely.
ADDITIONAL POSITION INFORMATION
Ability to effectively interact and communicate with all levels
within St. Charles Health System and external
Strong team working and collaborative skills
Ability to multi-task and work independently
Attention to detail
Excellent organizational skills, written and oral communication
and customer service skills, particularly in dealing with stressful
Strong analytical, problem solving and decision making
Demonstrated ability and experience in computer applications,
use of electronic medical record keeping systems and MS Office
Continually (75% or more): Use of clear and audible
speaking voice and the ability to hear normal speech
Frequently (50%): Sitting, standing, walking, lifting 1-10
pounds, keyboard operation.
Occasionally (25%): Bending, climbing stairs, reaching
overhead, carrying/pushing or pulling 1-10 pounds,
Rarely (10%): Stooping/kneeling/crouching, lifting,
carrying, pushing or pulling 11-15 pounds, operation of a motor
Never (0%): Climbing ladder/step-stool,
lifting/carrying/pushing or pulling 25-50 pounds, ability to hear
whispered speech level.
Exposure to Elemental Factors
Never (0%): Heat, cold, wet/slippery area, noise,
dust, vibration, chemical solution, uneven surface.
Blood-Borne Pathogen (BBP) Exposure Category
No Risk for Exposure to BBP
Schedule Weekly Hours:
First Shift (United States of America)
Is Exempt Position?
NON CONTRACT RN
Scheduled Days of the Week:
As Scheduled (may include weekends and holidays)
Shift Start & End Time: