- Assist in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers, in conjunction with the admitting/attending physician.
- Partner with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed.
- Conduct concurrent reviews as directed in the hospital's Utilization Review Plan and review of medical records to ensure criteria for admission and continued stay are met and documented.
- Along with other health care team members, monitor the use of hospital resources and identifies delays.
- Associate degree in Nursing from an accredited school
- Bachelor of Science in Nursing (BSN) from an accredited school of nursing (preferred)
- Three (3) years of recent clinical or utilization management experience
- Competence in standardized medical necessity criteria (preferred)
- Three (3) years of recent case management or utilization management experience. (preferred)
- Current Vermont RN licensure in good standing with no restrictions or stipulations or multistate compact licensure in good standing with no restrictions or stipulations
- Basic Life Support (BLS) for Healthcare Providers
- Accredited Case Manager (ACM) certification, Certified Case Manager (CCM) or Case Management Administrator Certification (CMAC) certification (preferred)
- Ability to understand, interpret, and explain data for utilization management functions.
- Highly developed written, verbal, and presentation skills.
- Possesses knowledge of care delivery systems across the continuum of care, including trends and issues in care reimbursement.
- Possesses mid to high-level proficiency in navigating the Electronic Medical Record and applications related to utilization management.
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Description
Job Description
Job DescriptionDescription:The Utilization Review Registered Nurse (RN) will:
