Utilization/Quality Review Nurse

Reports to the Director, Managed Care and Medical Director of Community Health Alliance (CHA). Conducts effective utilization and quality review through the monitoring of care provided during hospitalization and certain out-patient procedures according to utilization management guidelines for workers compensation and group accounts. Review includes pre-certification, admission, concurrent discharge and retrospective review on assigned accounts. Review may also include focused or targeted monitoring of out-patient services and physician office visits. Utilizes a case management approach. Also responsible for medical claims analysis through proper identification.

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.

Conducts effective utilization and quality review by:

• Maintaining accurate records, informing callers of where to call for benefits, assisting with appropriate referrals and identifying, before or at the time of admission, cases which are at high risk for discharge planning intervention.
• Educating providers regarding the purpose and goals of the programs and conducting appropriate referrals and follow-up on those cases which necessitate the use of a physician advisor; referring all cases which do not meet severity of illness-intensity of service criteria.
• Assisting in large case management and acting as a consultant in the medical analysis or refers all potential large cases to the appropriate outside case management Company.
• Striving, consistently, to enhance the review process through new knowledge and trial of innovative techniques, while maintaining confidentiality under HIPAA Guidelines.
• Conducting pre-certification of admissions or potential admission utilizing established guidelines, determining appropriateness of admission.
• Obtaining provider information on pre-certification and concurrent review, maintaining positive working relationships with preferred providers and payors and generating reports related to the UR/QA activity.
• Directing patients to appropriate providers through the pre-certification and review activity and establishing methods of data collection and monitoring to reflect UR/QA activity.
• Reassessing claim decisions when requested by the physician, employer or UR/QA Committee and striving, consistently, to enhance the medical analysis of claims through new knowledge and trial of innovative techniques.
• Assisting in the appeals process.
• Conducting and maintaining cases that are under the case management program. Establishes methods of data collection and monitoring to reflect utilization review and quality assurance activity.

Contributes to the overall effectiveness and efficiency of the department by:

• Maintaining accurate records, including monthly and year-to-date utilization statistics utilizing appropriate medical terminology and in accordance with established policies and procedures.
• Referring provider issues to the Medical Director or Director when follow-up is needed such as: patient or provider complaints, inappropriate billing practices or utilization problems.
• Maintaining working relationships with contracting providers, accounts, patients and employees; establishing and maintaining direct contacts to enhance the day-to-day operation of the UR/QA program.
• Participating in meetings and on committees as requested; attending all Health Resource Management Committee meetings
• Undertaking verbal and written communications to Hospital associates, physician's offices, UR/QA Committee and others, as necessary.
• Providing the Medical Director and Director with timely written and verbal communications, as requested.

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

• 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.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

• 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 from an accredited school of nursing; an undergraduate degree preferred. A minimum of two years experience in an acute care facility with at least one year of experience with utilization review, coding and/or case management is required. Previous experience with various reimbursement entities and/or claims management with a basic knowledge and understanding of Managed Health Care Programs (such as PPO, HMO, IPA, etc.) is required.

Knowledge & Skills

• Requires a thorough knowledge of Millimam and Robertson criteria, medical terminology and record systems and a strong understanding of managed care.
• Demonstrates the analytical skills necessary to analyze and compile data and generate reports accurately representing trends and information of utilization experience.
• Demonstrates the interpersonal and communication skills (both verbal and written) necessary to interact effectively to patients, visitors and physicians.
• Requires proficiency in basic computer skills (i.e., data entry, word processing, spreadsheets and data base applications).
• Requires the ability to pay attention to details, organize and prioritize work independently and utilize available resources.

Working Conditions

• Works in an office environment.

Physical Demands

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