RN - Utilization Review

Baptist Health Care
United States, Florida, Pensacola
Nov 08, 2024
Job Description The Utilization Review Nurse acts as a patient and organizational advocate. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost-efficient patient outcomes. Looks for opportunities to reduce cost while ensuring the highest quality of care is maintained. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically based case management, discharge planning, and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. The Utilization Review Nurse assists the nurse case manager, social worker, and physician to ensure the right care is provided at the right time every time by focusing on the person and family and ensures the patient's active participation and decision making in their care. Works collaboratively with interdisciplinary staff internal and external to the organization. Participates in quality improvement and evaluation processes related to the management of patient care. The Utilization Review Nurse is on-site and available seven days a week, as well as holidays and, therefore, is required to work a weekend rotation and an occasional holiday Responsibilities Assists in the development and implementation of the case management program. Directs, coordinates, and provides case management to patients in caseload. Provides clinical data/information to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request. Establishes and maintains effective communication with all referral sources, insurers, vendors, and patient supplier systems. Consistently maintains a professional commitment to institutions and department's goals and objectives. Demonstrates flexibility to the department's needs in relation to floor and work schedule and any other internal and external demands on the department. Continually shows commitment to the department by extending oneself when the need arises. Maintains knowledge and understanding of Managed Care and other payer requirements for appropriate level of care and necessity of continued stay. Maintains knowledge and understanding of Medicare/Medicaid regulatory requirements and Conditions of Participation. Maintains knowledge and understanding of Manager Care and other payer requirements for appropriate level of care and necessity of continued stay. Interacts, communicates, and intervenes with multidisciplinary healthcare team in a purposeful, goal-directed fashion. Works proactively to maximize the effectiveness of resource utilization. Anticipates, initiates, and facilitates problem resolution around issues of resource use and continued hospitalization and discharge planning. Maintains current knowledge of case management, utilization management, and discharge planning, as specified by federal, state, and private insurance guidelines. Qualifications Minimum Education Associates Degree Nursing Required or Technical Diploma/Certificate Nursing Required Minimum Work Experience 4-6 years broad based nursing experience Required About Us Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includes three hospitals, four medical parks, Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida. Baptist Health Care, Inc. is an Equal Opportunity Employer. BHC maintains and enforces a policy that prohibits discrimination against any workforce members or applicants for employment because of sex, race, age, color, disability, marital status, national origin, religion, genetic information, or other category protected by federal, state or local law.