Utilization Review Nurse

Mountain View Hospital is looking for a Case Manager/Utilization Review to join our team!

JOB SUMMARY:

Performs utilization review activities in accordance with all state and federal mandated regulations in order to evaluate the necessity, appropriateness and efficiency of medical services provided. Maintains compliancy with regulation changes affecting utilization review and case management. Reviews patient’s records assists in evaluating patient’s progress and performs continuing review for identification and need of on-going hospitalization. Obtains and reviews necessary medical records and subsequent treatment plans to conduct reviews. Reviews and validates physician orders are carried out, reports progress and unusual occurrences on patients to department supervisor. Ensures cost effective and appropriate health care services are provided to all patients regardless of patients funding. Assists in maintaining review and appeal logs, participates in interdisciplinary collaboration with professional staff. Assists collaborating with other departments in discharge planning. Supports clinical improvement activities of Mountain View Hospital and Idaho Falls Community Hospital by providing quality review. Performs administrative duties; receives and generates a variety of reports as needed. Assists in assessing the physical, functional, social, psychological, environmental and financial needs of patients. Assists with referrals to appropriate community resources and contributes to the assessment of patient’s support systems. Acts as a patient advocate by assisting in acquiring appropriate medical, nursing or other health care in the home or clinic setting as needed upon discharge. Maintains accurate patient records, ensuring patient confidentiality. Contributes and assists in the performance of case management activities, and contributes to the assessing, planning, implementing, coordinating, monitoring and evaluating of the needs of patients for services both during and after hospitalization. Assists the department head in the supervision of the utilization of resources to promote quality, cost-effective outcomes for the patient and the patient’s family.

BENEFITS:

Taking care for our community starts with taking care of our own team. Mountain View Hospital is proud to offer its employees competitive and comprehensive benefit packages. Benefits include:

• Medical, Dental and Vision Insurance
• Paid Time Off (vacation, holidays and sick days) and Medical Paid Time Off
• Retirement Plans (401K with up to 6% match)
• Earned Quarterly Bonus Program
• Education Reimbursement Program
• Discount for medically necessary procedures performed at Mountain View Hospital and Idaho Falls Community Hospital
• Life Insurance
• Short- and Long-Term Disability
• Flexible Spending Accounts
• Employee Assistance Program
• Flexible Schedules
• Collaborative and Supportive Work Environment

Please note benefits are based on eligibility according to full-time, part-time or PRN status classification.

DUTIES AND RESPONSIBILITIES:

• Assist the Supervisor of the department with daily activities of the department including chart review, interaction with patients and physicians, and with the floor nursing staff as well as other departments within the facility.
• Justify pre-admission, admission and continued stays per InterQual criteria, by utilizing the InterQual manuals, in accordance to severity of illness, intensity of service and discharge criteria.
• Works closely with the department Supervisor, regarding Utilization Review and Case Management principles.
• Performs utilization review and Case Management activities, and will be an active member of the utilization review committee.
• Some interaction with physicians and hospital staff on Utilization Review and Case Management issues.
• Assists with the Follow through on appeals for Medicare, Medicaid, and commercial insurances in an effort to retrieve funds from denied patient stays under the supervision of the department supervisor.
• Assists in the Review of patient cases with Medicaid, via Qualis Health, and various commercial insurances, on an initial, concurrent and retrospective basis, using InterQual criteria to ensure appropriateness of patient’s length of stay.
• Contribute to the collection of information on the patient’s level of functioning and personal living situation in order to develop an action oriented case management plan that is time specific to best assist the patient during their hospital stay and upon discharge from the facility.
• Assist the multidisciplinary team with the execution of the case management plan to achieve the desired outcomes for the patient.
• Monitors the case management plan, and reports to the department supervisor to make changes as needed, to achieve the desired outcomes for the patient, with the assistance of the utilization review / case management staff.
• Assists with the arrangement of appropriate services for the client, both during the patients stay and after discharge, utilizing all resources.
• Contributes to the monitoring of the patient during their hospital stay, and identifies specific needs which are reported to the department Supervisor so the team can intervene on the patient’s behalf when needed.
• Assistant will be able to cover for the Supervisor in times of Supervisors absence from the department with the direction of Social Services LSW.

About Mountain View:

Mountain View Hospital and our 29 affiliate clinics are committed to providing compassionate, cutting edge care to our patients. We serve the entire Snake River Valley – all the way from Pocatello to Rexburg. Our medical capabilities span everything from wound care to urgent care, oncology to neurology, physical therapy to speech therapy, a Level III NICU, robust robotic surgery department and a continuously expanding rural health practice.

Our work environment is mission driven, people-centric and supportive. It is what sets apart and makes people excited to come to work each day. If you are looking for a career where you can make a difference in your community, we invite you to apply.

Education/Certification: Graduate from an accredited school of nursing with current license as an LPN or Registered Nurse in the state of Idaho, with specialized training and/or experience in Utilization Review. Strong knowledge of modern nursing principles, techniques, and procedures for the care of patients, with emphasis on growth and developmental needs of patients from birth to death. These skills may be obtained through formal educational programs, training or experience. A strong knowledge base is needed in medical terminology, anatomy and physiology, and concepts of disease.

Experience: Minimum Three years nursing.

Equipment/Technology: Computer and Internet experience

Language/Communication: Excellent written and verbal skills

Mathematical Skills: Excellent

Mental Capabilities: Must have excellent critical thinking skills.

Interpersonal: Shall at all times demonstrate professional behavior.

Performance: Must work well under pressure and meet multiple deadlines, and be able to multi-task.