JOB DESCRIPTION: Notifies attending physicians and Interdisciplinary Patient Care Teams of all denied and pended for medical review days. Complies with established policies and procedures and implements appropriate changes to the Utilization Management process as directed. Takes action to achieve annual departmental goals. Provides information including thorough, accurate and timely clinical updates to comply with regulations of third party payors and federal and state regulatory agencies and to obtain approvals of LOS and facilitate accurate payment of claims. Participates in discharge planning. Attends Interdisciplinary Patient Care Team meetings and assigns tentative LOS on initial review of patient record. Initiates referrals to Social Services as appropriate. Assumes responsibility for identifying impediments and communicates and/or addresses barriers to timely discharge. Reviews each hospital admission in accordance with nationally recognized criteria and department policies to determine the medical necessity of admission and appropriate LOS. Intervenes as required with physicians and Interdisciplinary Patient Care Teams to facilitate achievement of targeted LOS. Communicates and provides financial data regarding the patient's hospital admission and LOS when appropriate. Issues and administers notices of non-coverage and potential of liability to clients in accordance with predetermined regulations, policies and procedures. Collects and records required Utilization Management information for appropriate management of the patients in the units to which they are assigned. Maintains accurate, legible, confidential documents and records pertaining to medical reviews. Facilitates the review process by ensuring the timely delivery of materials to the appropriate personnel. Serves as a resource to Interdisciplinary Patient Care Teams and physicians for the interpretation of external regulations and organizational policies and procedures pertaining to the utilization Management process. Communicates nationally recognized criteria as appropriate. Utilizes medical knowledge as an advocate for the patient to provide pertinent information to third party payors. Serves as a liaison to assigned nursing units to facilitate the Utilization Management process and to ensure the continuity of patient care. Identifies LOS and/or insurance issues and informs Interdisciplinary Patient Care Team for response. Works with third party payor representatives as an organizational representative. Facilitates MD to MD reviews as needed. Maintains an effective flow of information between the nursing units, Social Services, physicians, Medical Records, Business Office and third party payors to facilitate appropriate lengths of stay (LOS) and to ensure appropriate reimbursement and coverage. Identifies, addresses and reports all quality issues to appropriate parties in a professional manner.
MINIMUM QUALIFICATIONS: Graduate of an accredited nursing program. Currently licensed as a Registered Nurse in the state of Georgia. Two years of recent health care experience (within the past five years) and one year of experience in utilization management, quality improvement, or discharge planning. A bachelor's degree in nursing or related health care field preferred.
PHYSICAL REQUIREMENTS (MediumMax 25lbs): up to 25 lbs, 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 25 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.