Utilization Review RN - Irving, United States - Baylor Scott & White Health

Description

SCHEDULE:

JOB SUMMARY
The Utilization Review Registered Nurse (RN) provides a clinical review of cases using medical necessity criteria to resolve the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with the health plan, provider utilization and/or care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Partners as a team to ensure that medical records help the level of services being delivered.

ESSENTIAL FUNCTIONS OF THE ROLE

• Performs initial, concurrent, discharge and retrospective reviews.
• Uses evidence-based medical guidelines to resolve the medical appropriateness of inpatient and outpatient services; Assesses patient needs; Uses knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients; Identifies, escalates and resolves complex cases or issues as required.
• Reviews medical records to verify that the content helps an appropriate level of care (inpatient, observation, bedded outpatients) or type of service.
• Alerts and partners with appropriate Utilization Review, Physician leadership and/or Provider Team personnel concerning patients who do not meet medical appropriateness criteria.
• Coordinates with necessary parties when there are potential or actual denials.
• Facilitates appeals or the delivery of appeal instructions when denials occur.
• Facilitates authorization process for admissions and continued stays.
• Uses knowledge of nursing process and pathophysiology to anticipate discharge needs.
• May participate in discharge planning through discussions with the care team as needed.
  
• Communicates issues or trends with specific entities, providers or payors to the appropriate leadership.
• Provides help to complex cases or escalations within scope of licensure or refers them to appropriate leadership.
  
• Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.
• Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies, and procedures to continuously enrich care coordination efforts and ensure evidence-based processes are utilized.
• Performs service recovery efforts to help provider and member satisfaction.

KEY SUCCESS FACTORS