UNAVAILABLE
On-siteSalt Lake City, Utah, United States
Job Summary
Monitor admission appropriateness and continued stay reviews by applying approved utilization criteria to ensure medical necessity. Communicate with third-party payers for initial and concurrent clinical reviews, documenting all actions shared with the care team. Alert physicians and case managers when patients no longer meet criteria, discussing resource utilization appropriateness and referring cases to the UR committee for over-utilization. Track length of stay and costs to identify at-risk patients, collect data on variances and denied days, and prepare appeals. Perform verbal or fax clinical reviews with payers as determined by nursing judgment. Work rotating schedules including variable hours, weekends, nights, and holidays to meet 24/7 staffing demands in a Level 1 Trauma Center environment.
Required Qualifications
- One year Utilization Review or Case Management experience
- Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah
- Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah
- Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment
- 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
- Regular, reliable, and punctual attendance during assigned shifts
Desired Qualifications
- Basic Life Support Health Care Provider card
- Proficiency in application of InterQual Criteria, knowledge of ICD-9, DRG's and CPT Codes
- Utilization Review Certification designation
- Knowledge of CMS Regulations
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