Registered Nurse

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  Initial clinical assessments, continued stays assessments, and payer requested reviews are performed using evidence based criteria as designed, medical experience based problem solving skills, and following the established policies and regulations governing this process in order to either obtain authorization or establish medical necessity for hospitalized patients.
• Hold collaborative discussions with physicians on the medical staff, when needed, to obtain additional documentation in the record to support hospital medical necessity, discharge needs, or fulfill other payer requirements. These discussions are to help the UR Clinical Specialist understand the reason for admission, and better be able to request appropriate additional documentation from the physician(s).
• Escalates cases to the Utilization Review Manager and/or Physician Advisor if physicians are unable to provide any additional information to support the need for medically necessary hospital care.
• Documents all actions and activities in the case management software system used by the hospital. This documentation includes, but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, wDRG etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies/procedures.
• In the event of concurrent denials, the UR Clinical Specialist reviews the denial and works with the physicians on the medical staff hospital’s to perform an internal secondary review to determine if there is need to downgrade the visit. The UR Clinical Specialist may assist coordinating a Peer to Peer discussion according to hospital and/or corporate direction. Results of the Peer to Peer are to be gathered from the physician presenting after the call and documented in the case management system by the UR Review Specialist.
• In the event a facility does not have an ED Case Manager present, the UR Clinical Specialist will collaborate with Emergency Room Physician/staff on ALL potential admissions during assigned hours to:

• UR Clinical Specialist communicates with the UR Coordinator and facility case manager(s) (i.e. licensed social workers, discharge planners, etc.) in –person, telephonically, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient’s care.
• Perform other duties as assigned.

This position is at the Spring Hill location processing denials.

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  Active FL. RN License

• 5 years acute care experience and 2 years Case Manager (CM) Experience

• CM experience preferred at an acute care hospital

• Discharge Planning Knowledge