On assigned nursing units, abstracts pertinent data from the designated medical records, determines medical necessity and assigns length of stay using approved criteria. Admission reviews are performed within 24 hours of notification of admission (exclusive of weekends and holidays); continued stay reviews are preformed at least by the dates of expiration of the previously assigned length of stay.

 

Assigns initial length of stay in accordance with established norms or certifies admission and continued stays with commercial insurance companies.

 

Refers questionable cases in which medical record documentation does not support approved criteria for admission or continued stay to the physician advisor of the UR Committee.

 

Contacts physicians regarding problems with utilization management agencies approval of hospital stays.

 

Follows appropriate procedures for issuing Termination of Benefits letters when the physician advisor denies a referred case with concurrence of the attending physician or by the commercial insurance.

 

Communicates obtained authorization numbers to the Business Office and physician’s offices as appropriate.

 

Reviews Surgicare cases for appropriateness of setting and precertification requirements

 

Monitors Observation cases for appropriateness of setting. Completes form for the correct beginning and end times of the Observation charge. Faxes completed form to the admissions department.

 

Communicates with other hospital departments in matters of review decisions.

 

Assists the coders with determining discharge diagnoses to ensure maximum reimbursement and accuracy.

 

Completes daily statistical reports.

 

Maintains current knowledge of Medicare, Medicaid, QIP and AOA regulations and requirements along with the precertification/concurrent review monitoring requirements for the various utilization management agencies/insurance companies—particularly those with whom the hospital has a contractual agreement.

 

Insures the QIP and AOA guidelines for Utilization Review are followed.

 

Evaluates and initiates action on QIP correspondence i.e., pending and financial considerations, quality issues, chart copy requests and chart copy destructions.

 

Completes the Case Management screen on all inpatients and observation cases the first working day following admission. Initiates discharge planning on any patient identified as needing a discharge plan developed by the screening process or by the patient’s physician request, any member of the multidisciplinary team, the patient or a person acting on the patient’s behalf.

 

Participates in the multidisciplinary patient rounds as assigned.

 

Defines the scope of responsibility within the multidisciplinary patient care team. Judges relevancy and determines significance of any identified discharge planning issue, utilizing various stragies and resources to achieve problem resolution. Assesses patient’s needs for intervention by other disciplines and refers when appropriate.

 

Assesses patients for level of care and care requirements in anticipation of transfer to alternate facilities, including Swings beds, and assists to accomplish these transfers.

 

Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients assigned.

 

Maintains relationships with nurse liaisons, case managers and social service staff who represent outside agencies, services, or facilities.

 

Assesses patient’s needs for teaching and collaborate with nursing service to ensure it is completed prior to discharge.

 

Documents pertinent information and status of discharge arrangements in the medical records in a timely fashion. Documents discharge planning interventions on the plans of care for assigned cases.

 

Completes required continuous training and education, including department specific

requirements.

 

Supports and is involved in the hospital QI initiatives.

 

Participates on hospital committees as appropriate.

 

Attends monthly departmental staff meetings.

 

Adheres to all departmental/hospital policies.

 

Is CPR certified and recertified as needed.

 

Performs other duties as assigned.

 

Agrees to comply with the Corporate Compliance Policy and all laws, rules, regulations, and standards of conduct relating to the position and has the duty to report any suspected violations of the law or the standards of conduct to his or her immediate supervisor, the Compliance officer, or the Chief Executive Officer

 

Minimum Knowledge, skills and abilities required

 

Knowledge regarding hospital protocols and procedures: familiarity with community resources and outside professional agencies; familiarity with federal and state regulations governing hospital and home care; and good assessment and problems solving skills.

 

Extensive knowledge and understanding of medical terminology and medical science (disease processes) for effective review of medical records.

 

Working knowledge of ICD-9-CM Coding System and DRGs and CPT coding.

 

Thorough knowledge of QIP, AOA and Medicaid requirements.

 

Ability to use a computer.

 

Ability to work under pressure, adapting to fluctuating work loads.

 

Good interpersonal skills and communication skills to effectively communicate with physicians, nursing staff, patients, and others as required.

 

Education and Experience required

 

Licensed Registered Nurse with recent 2-3 year medical/surgical experience in a hospital setting. A degree from an accredited Baccalaureate program is preferred. Experience in Utilization Review or Discharge Planning is most desirable.