• Responsible for conducting and coordinating medical necessity reviews for all patients upon admission to inpatient or observation status and complete continued stay reviews throughout the stay. 
• Evaluates surgical schedule for inpatient only procedures (IPOs) and communicates via message system the need for appropriate orders.
• Verifies physician orders in the medical record follow Medicare and other payer guidelines for determining level of care. Assures medical documentation accurately reflects the severity of illness and acuity of the patient.
• Communicates with KHI medical staff as needed to reconcile and clarify admit orders and/or medical documentation to ensure that the hospital is reimbursed appropriately for services rendered.
• Consults with Physician Advisor as needed to make medical necessity determinations and or make referrals for cases not meeting criteria as per KHI Utilization Management Plan.
• Works collaboratively with Case Managers and Insurance Specialist to ensure that appropriate and accurate clinical information is communicated to payers within required timeframes as per KHI policies and procedures.
• Responsible for complete, accurate and timely entry of information related to the utilization review process into data systems. Maintains documentation of all activities to support medical necessity determinations.
• Collaborates with all members of the healthcare team, the business office, and payers as necessary, to ensure patients receive high quality care in the most cost-effective manner. 
• Collaborates with Denials Manager and RAC team to identify issues and/or trends related to medical necessity denials. Participates in the denials management process. 
• Serves as a resource to Case Management staff and provides education and coaching regarding appropriate use of clinical guidelines, utilization review and payer regulations.
• Establishes communications system for days off.
• Assists in sending admitting and discharge clinicals on all patients

Review Process:

• Reviews Medical Records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria. 
• Evaluates medical information against nationally recognized criteria and determines necessity for admission, continued stay, appropriateness of service, and/ or level of care.
• Collaborates with the physicians to determine appropriate inpatient versus observation status and ensure appropriate documentation, and appropriate orders are entered.
• Perform Code 44 when needed and communicates downgrades to appropriate staff.
• Notifies Admitting, Insurance verifiers, and Apogee regarding status change of admission via email.
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Utilization:

• Determines which cases will require medical staff review intervention and/or UR management intervention. 
• Factors such as appropriateness, quality, etc., are taken into consideration during the Case Management process.
• Communicates with the attending physician, expected length of stay, Medicare guidelines and individual variances. 
• Collaborates with the Case Managers and Insurance Specialist to ensure appropriate documentation, awareness of potential denials, and any needs of clarification within the EMR from physician.
• Assists in educating Case Managers, Social Workers, and Physicians, changes in CMS guidelines, documentation requirements, etc. 

Quality of Care: Protects patients’ rights as they pertain to the ethical and legal issues of confidentiality during the case management process.

Compliance:

• Participates in committees, performance improvement activities, mandatory in-services, and continuing education. 
• Maintain compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines.

Additional Duties: Perform additional duties, as requested, such as: focused studies, appeal letters, outlier reporting, patient satisfaction initiatives, etc.

Education: Graduate from an accredited school of nursing

Experience:

• Minimum of three years clinical experience as an RN preferably in a hospital medical surgical or critical care setting.
• Minimum one year of utilization review experience or two years case management experience as an RN

Licensure: Current, valid Arizona or compact state RN license

Certification: N/A

Knowledge, Skills, and Abilities:

• Must have strong clinical skills and knowledge, and the ability to recognize when quality issues exist.
• Knowledge of nationally recognized criteria used to make medical necessity determinations. Experience using Milliman or InterQual criteria preferred. 
• Strong interpersonal, organizational, and motivational skills, as well as proficiency in written and verbal communication.
• Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
• Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open-minded, and adaptable to change. 
• Good assessment skills and knowledge of clinical and social factors that may affect the patient’s functional status at discharge

Education: BSN or MSN

Certification: CCM or ACM (will allow for time to obtain)

Exposure Categories:

• Blood Borne Disease Exposure Category II.
• Other potential Hazard(s): Volatile/violent patients or family members.

• Able to handle multiple priorities simultaneously.
• Able to manage technical business equipment i.e., phone, fax, computer etc. 
• Ability to sit for 5-8 hours per day.
• Ability to stand for 3-5 hours per day.
• 5. Ability to walk for 3-5 hours per day.