Utilization Review Nurse

Major Responsibilities:

• Documents utilization review activity per department and medical center standards in a timely manner. Performs and documents accurate and timely concurrent and retrospective reviews based on approved established criteria.
• Communicates effectively with the healthcare team. Works closely with medical staff, hospital departments and ancillary services as part of Outcome Facilitation Team/Multidisciplinary Team in expediting care delivery to avoid delays in timely service provision and implementing and reporting utilization management (UM) activities, as applicable.
• Collaborates with managers, physicians, medical directors, advisory groups and treatment teams for issues related to physician practices and best practices for the patient’s plan of care. Refers cases to physician advisor as needed to ensure accurate status and compliance with regulatory guidelines.
• Remains knowledgeable in issues of healthcare regulations, reimbursement issues, impact on length of stay and community resources. Provides clinical updates to payers and/or external review organizations, collects data, coordinates denial activity, supports UM activity, and manages avoidable delays.
• Develops and maintains productive relationships with community-based agencies and networks by representing Aurora Health Care in a positive manner working collaboratively, internally and externally, to meet patient/family needs.
• Serves as an educator and expert resource to medical and hospital staff regarding admission status and acute care criteria, utilization management issues, and relevant regulatory requirements.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and/or Certification Required:

• Registered Nurse WISCONSIN license issued by the state in which the team member practices.

Education Required:

• Bachelor's Degree (or equivalent knowledge) in Nursing.

Experience Required:

• Requires 3 years of experience in clinical nursing, case management, insurance, utilization and/or quality management.

Knowledge, Skills & Abilities Required:

• Must have working knowledge in the use of Microsoft Office (Excel, Outlook, PowerPoint and Word) or similar products.
• Knowledge of the components of quality and acute care patient care needs specifically related to the area/function in which care management will be performed.
• Demonstrates working knowledge of Utilization Review criteria as demonstrated by achieving 80% or greater on the annual InterRater Reliability (IRR) competency exam.
• Utilizes critical thinking skills to analyze and synthesize clinical scenarios as it relates to application of medical necessity criteria.
• Excellent analytical and interpersonal communication skills necessary to interact with families, patients, physicians, and third party payers.
• Ability to manage conflict appropriately, seeking a win-win outcome by communicating issues in accordance with the Aurora Service commitments.
• Promotes effective professional relationships with physicians and other professionals in a direct and positive manner.
• Takes responsibility self-development by seeking out opportunities for professional growth and development and being an active participant in department, hospital, and system initiatives.

Physical Requirements and Working Conditions:

• Must be able to sit for approximately 50 percent of the workday; stand and walk for the equivalent of several blocks at a time.
• Must lift up to 10lbs. continuously and up to 20 lbs. frequently.
• Manual dexterity required for operation computer and calculator.
• Visual acuity required for facilitating review of written documents/computer screens, medical records, and to record information accurately.
• Clear verbal communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
• Exposed to normal office environment; including usual hazards related to operating electrical equipment.
• Operates all equipment necessary to perform the job.
• May be exposed to mechanical, electrical, chemical, and radiation hazards as well as blood and body fluids; therefore, personal protective equipment must be worn as necessary.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.