Utilization Manage Nurse (BHS)

Reports to the Manager. Serves as a liaison between Memorial Hospital, physicians, third-party payors and auditors to ensure information needs are met. Responsibilities include the review of medical records to determine the appropriateness and medical necessity of hospitalization. Coordinates and maintains the appeal process for denied hospitalizations. Maintains confidentiality regarding all information collected.

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Maintains systems for monitoring patient admissions and extended stays for appropriateness and medical necessity by:

• Reviewing patient admission clinical information using clinical criteria and guidelines available to assist the physician in the determination of medical necessity and/or appropriate admission status (inpatient or outpatient).
• Communicating, in a timely manner, with third-party payors to justify admission or continued stay.
• Reviewing extended stays prior to expiration of initially-assigned length of stay.
• Referring questionable medical necessity or extended stays to the Manager/Director, treating Physician (or Medical Director) as appropriate.
• Interacting with other Hospital departments in matters related to review decisions and fiscal communications.
• Facilitating discharge planning by working closely with Nurses and Clinical Social Workers and/or Therapists.
• These functions apply to associates assigned to Epworth Center only:
• Maintains system for monitoring and completing Medicare Certification/ Recertification for inpatient psychiatric services.
• Submission of 1261A forms within 14 days of admission for each Medicaid Psychiatric admission.

Anticipates and reviews denials and facilitates the appeal process by:

• Anticipating and reviewing denials by payors for lack of medical necessity, inadequate medical information or delay in discharge; also intervening by written appeal to avoid loss of revenue.
• Arranging physician-to-physician clinical reviews with insurance company, Medical Director and Attending Physician.
• Writing denial appeal letters on behalf of the patient and/or the Hospital, when appropriate, to avoid loss of revenue.
• Coordinating with the Manager/Director (and other management as appropriate) to identify and correct weaknesses in the admission and patient care process that can mitigate future denials.
• Issuing Notices of Non-coverage (insurance &/or Medicare) to patients as necessary.

Serves as a Memorial Hospital and Beacon Health System resource regarding reimbursement by:

• Maintaining knowledge regarding current regulations (PRO, TJC, AHA, etc.) which impact utilization review activities.
• Meeting with physicians, Hospital staff, review agencies, insurance companies and others (as relevant) in the assessment of utilization needs.
• Educating patients and patients' families regarding Medicare regulations and issues, and notices of non-coverage when appropriate.
• Identifying risk issues concurrently with clinical reviews to provide the Hospital management with valid information on potentially compensable events; also communicating with the Manager/Director and the Director, Risk Management.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Looking for opportunities to improve departmental operations, patient care delivery and utilization of acute healthcare resources; also striving for continuous quality improvement.
• Staying current on trends related to medical necessity, DRG and Recovery Audit Contractor (RAC).
• Completing other job-related assignments and special projects as directed.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

• The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a Nursing program. A valid and current Registered Nurse license in the state of Indiana is required. Two years of clinical experience is required. Two years of progressively responsible experience in a utilization review environment is preferred.

Knowledge & Skills

• Requires fundamental knowledge of the revenue cycle process, which includes such things as patient access, utilization review, charge capture, HIM and patient accounting.
• Requires the advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation and identify variances in standards of care.
• Requires knowledge of rules and regulations pertaining to hospital reimbursement.
• Requires familiarity with managed care principles and an understanding of post-acute continuum of care.
• Requires the interpersonal skills necessary to maintain effective working relationships and interact effectively with staff, physicians, review agencies, insurance companies, patients and patients' families.
• Requires the effective communication skills (both verbal and written) necessary to prepare documentation, write appeal letters and to provide education to staff and physicians regarding the revenue cycle process.
• Demonstrates the ability to be self-motivated, detail oriented and make independent decisions. Also demonstrates the ability to respond quickly and appropriately to customer requests.
• Demonstrates a working knowledge of the Hospital's computer systems (e.g., Star McKesson, Cerner Power Chart) and proficiency in computer skills (i.e., word processing, spreadsheets, utilizing the internet, etc.).

Working Conditions

• Works in an office environment and patient care areas when making rounds to review medical records. Will travel between various Memorial facilities if assigned to Epworth Center.
• May have contact with patients and family members who may be under considerable stress.
• May be exposed to bio-hazards.

Physical Demands

• Requires the physical ability and stamina to perform the essential functions of the position.