Are you interested in becoming part of an outstanding team of professionals who make patient and family-centered care their priority? We currently have the following opportunity for an energetic, skilled, and compassionate individual like you to become part of the Lake Health team.
Position Summary: The UR Gatekeeper Nurse monitor's adherence to Hospital's Utilization Review Plan to ensure the effective and efficient use of hospital services. Assists physicians and mid-level providers in the determination of the appropriate level of care assignment both at the time of initial placement to the hospital from all points of entry and as the patient's clinical condition evolves. Monitors the appropriateness of hospital admissions and placement in observation. Monitor the Observation patients through their entire stay to ensure all core measures are completed timely.
Essential Job Functions:
Reviews medical records for appropriate application of medical necessity criteria to determine the appropriateness of admission using industry-accepted level of care criteria and clinical expertise.
Uses clinical expertise and critical thinking to document within the Utilization Review systems the clinical justification found in the medical record to support hospitalization.
Accurately and completely documents clinical reviews in accordance with documentation standards, policies, procedures and/or guidelines.
Enters clinical reviews into the UM workflow management system sufficient for the Utilization Review Nurses to ensure necessary concurrent clinical information is transmitted to third-party payers.
Monitor the Observation patients through the entire stay and ensure all testing is completed timely.
Assist physicians through rounding to ensure the patients are in the correct status, receiving appropriate core measures, and monitor for avoidable days.
REDUCTION OF REVENUE LOSS:
Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions; to include admission through the emergency department, direct admission and admissions following a procedure.
Screens new inpatient admits, and new/current observation patients to identify the appropriate level of care based upon documentation in the medical record.
Communicates patient admission status information to business operations staff in a timely manner such that patients obtain timely and appropriate care in the hospital setting as required by their clinical conditions.
Communicates with admitting physician and emergency department physicians regarding patient's clinical condition, signs and symptoms as needed to ensure the patient's admission status is supported by the physician's documentation consistent with industry accepted guidelines and payer rules/regulations.
Performs clinical review for patients in Observation status to ensure that continued treatment in the hospital setting is medically justified and documented in patient's medical.
Monitors diagnostic workup, clinical progress, signs and symptoms as needed to ensure the timely evaluation of patient's outpatient workup and movement to the most appropriate setting (inpatient admission or discharge).
Utilizes critical thinking in all interactions to identify variances/problems, and apply sound decision-making skills.
Ensure that avoidable admissions, timely evaluation of observation patients and variances from status recommendations are captured and documented per guidelines.
Communicates pursuant to Department processes with Care Coordination, nursing staff and Clinical Decisionmaking Unit staff to assist with the management of length of stay and avoidable days.
UTILIZES CURRENT TECHNOLOGY:
Utilizes InterQual and/or MCG Guidelines.
Demonstrates identification of inpatient versus outpatient status, with a knowledge of screening criteria.
I.T. Systems Application and Knowledge
Utilizes computer systems effectively, with a clear understanding of Microsoft Office products.
Demonstrates clear understanding of hospital's Electronic Medical Record and Financial System technology
PROMOTES/SUPPORTS UR DEPARTMENT FUNCTIONS:
Complies with CMS rules and regulations, and Conditions of Participation, and payor-specific guidelines to prevent denials and revenue loss.
Performs utilization review and status recommendations in a timely manner, per established department work-flow, CMS and/or payer-specific guidelines.
Possesses UR management skills to effectively manage assigned caseload, per established organizational standards and policies.
Collaborates with the Care Coordination department staff and other members of the healthcare team regarding target length of stay (LOS), acute care criteria, payer requirements, resource utilization, and care options to meet patient needs.
Monitors and tracks delays in services.
Collects and documents admission recommendation data necessary for Utilization Management Committee reports.
COMMUNICATION AND COLLABORATION:
Communicates with Physicians, Third Party Payors, and other members of the interdisciplinary team to ensure correct status per guidelines and standards.
Coordinates to ensure that collaboration is maintained with multidisciplinary teams to help improve patient outcomes.
Acts as a liaison with the Care Coordination department to facilitate the appropriate utilization of hospital resources and timely discharge. Tracks and reports trends of inappropriate utilization of resources.
Document pertinent patient information and notify of any demographic or insurance changes through the appropriate departments.
Communicates pertinent clinical and/or regulatory information to the appropriate hospital, physician, and/or payor, both effectively and professionally.
OTHER JOB RESPONSIBILITIES:
Attends and actively participates in staff meetings. Participates in committees as requested. Participate in rounding with physicians.
Provides orientation of other UR Nurses, as requested.
Refers cases that do not meet established guidelines for admission or continued stay consistent with the second level review arrangement
Participates in a regular rotation of weekend and after-hours coverage in order to meet Department needs as determined by the Director.
Education and Experience:
Bachelor's degree in Nursing (BSN) or Associate's degree in Nursing (ASN) with Bachelor's degree in a closely related field required. Licensed as a Registered Nurse. Certification in clinical case management or utilization review strongly desired. Previous experience in an acute care hospital patient care setting preferred.3 years nursing experience prior to utilization review required; at least 5 years preferred.
Lake Health offers free, secure and convenient parking; an aggressive pay structure, tuition reimbursement and continuing education funding programs, a generous and comprehensive benefits package for all eligible positions which includes medical, dental, vision, pension, paid time off; an award winning hospital system recognized for excellence in patient care and as a "Best Place to Work." Apply on-line today at http://www.lakehealth.org/Careers
Key Words: RN, Nursing, Utilization
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled