Registered Nurse Utilization Review Coordinator

Location

Ithaca, NY | United States

Job description

Job Title: Utilization Review Coordinator

Department: Clinical Resource Management

Reports To: System Director of Utilization and Case Management

Job Summary :

Cayuga Health System seeks a motivated and experienced individual to join the Clinical Resource Management Team in the role of Utilization Review (UR) Coordinator. The UR Coordinator monitors daily activities and utilization management functions across the system in accordance with the goals and objectives of the CHS Utilization Review Plan.

UR Coordinator maintains knowledge of CMS Conditions of Participation for Utilization Review and functions as a resource for the Case Management team on issues involving appropriateness of admission, level of care determinations, and the issuance of Hospital Issued Notices of Non-Coverage (HINNS). The UR Coordinator supports the UR Committee - preparing/presenting data and documents as indicated. The UR Coordinator monitors medical necessity denials and facilitates peer-to-peer discussions, generating technical and medical necessity appeals as indicated per payer requirements.

The UR Coordinator collaborates with provider offices and surgical scheduling to assure appropriate authorizations and provides guidance as indicated to network partners and affiliates. The UR Coordinator also maintains knowledge of Swing Bed PDPM reporting and billing including entering appropriate HIPPS codes into the CMC billing system for submission.

Job Responsibilities include:

• Demonstrates knowledge of medical necessity criteria and guidelines. Assist in the prospective, concurrent, and retrospective review of clinical cases to identify the most appropriate level of care based on nationally recognized criteria and standards of care.
• Monitors patient status, collaborating with patient access and providers to ensure alignment with physician orders.
• Participates in the analysis of Utilization trends and makes recommendations as indicated.
• Serves as a resource for the CRM team, and system at large, in daily concurrent review activities.
• Assists Director in the education of physician offices related to trends found in the surgical authorization process and related to authorization standard requirements communicated from third party payers.
• Implements and oversees the Clinical Resource Management medical necessity denial process. Assures ongoing tracking and trending of denial information and appeal activities.
• Maintains current knowledge of regulatory and compliance requirements for utilization practices, policies and procedures.
• Maintains accountability for the utilization management process across the system.
• Maintains working knowledge of the organizational and department objectives and goals and takes actions to achieve targeted outcomes.
• Maintains current knowledge of federal, state and accreditation standards related to UR and Discharge Planning requirements.
• Participates in system taskforces and other collaborative activities with community partners to support facility growth and transitions of care.
• Maintains high visibility and is readily approachable.
• Communicates effectively with care teams, patients, families and guests.
• Remains calm in stressful scenarios and able to resolve conflict independently, appropriately escalating concerns as indicated.
• Regularly attends team meetings. Seeks information missed where unable.
• Flexible in taking additional assignments as needed to cover for planned and unplanned events.
• Demonstrates and promotes teamwork, the ability to remain flexible and re-prioritize to cover staffing changes or gaps.
• Appropriately shares knowledge with coworkers
• Proactively participates in developing case management programs within the department and seeks out new learning experiences
• Demonstrate strong written and verbal communication skills. Enforces appropriate written and verbal communication among team members
• Exemplify satisfactory attendance and punctuality record as set forth by CHS policies.
• Exemplify a professional image in appearance, manner and presentation.
• Maintains patient confidentiality in the provision of high quality care.
• Is flexible in assuming other responsibilities not noted above.

Requirements :

Education - Graduation from accredited nursing program. BSN in nursing preferred.

Experience - Minimum 2 to 3 years' experience in an acute care hospital setting or equivalent health care experience. Knowledge of federal, state and accreditation standards. Strong written and verbal communication, organization, critical thinking and problem solving skills required.

Licensure - Current unrestricted NY state RN licensure.

Physical - Ability to stand, sit or ambulate for long periods. Ability to mobilize freely around units, transport self to site locations, and perform required data entry into EMR and alternate data management systems. Ability to transport self to customer base.

Cayuga Health System Commitment to Diversity, Equity & Inclusion

Cayuga Health System commits to treat all people with dignity so that everyone who comes to us is safe, cared for, and respected. We will support the growth of our employees and the health of our community by embracing the rich diversity of social and cultural identities, needs, and life circumstances of all people. We strive to recognize and overcome personal biases and systemic policies that marginalize others and contribute to disparities in healthcare access, equitable care, and good health outcomes.

Cayuga Health is dedicated to our vision for diversity, equity, and inclusion. As we strive towards our vision, we welcome the opportunity to work alongside a diverse range of employees

Job tags

Salary