Utilization Review LPN

Job Summary: The Utilization Review Nurse is responsible for compiling and reviewing the medical information of individual patients and the insurance coverage available to them. The Utilization Review Nurse must be able to balance the quality of patient care with cost efficiency and is responsible for considering appropriateness/necessity of services prior to authorizing them or preparing cases for physician review. 

DUTIES AND RESPONSIBILITIES:

• Authorizes requested medical services. Prepares cases for physician review.
• Compiles and reviews medical information and insurance coverage.
• Informs patients about their benefits and coverage limits.
• Identifies alternative, cost-effective resources. 
• Reviews observation charts to determine appropriateness and if patients continue to meet criteria for length of stay. Communicates with the Discharge Planner and/or Care Coordinator the results of the review daily.
• Communicates with the Emergency Department and/or providers as to whether a patient meets criteria for an admission to Appling Healthcare. 
• Assists the Care Coordinator with follow-up phone calls to ER patients and assists with referral to resources.
• Identifies inpatient and observation charts that do not meet established criteria and confers with the attending physician. 
• Stays up to date on all Medicare, Medicare Advantage, Medicaid, and private insurance guidelines from notification of admission to when clinicals are due.
• Ensures stay interviews are completed for all insurance companies by the assigned review date.
• Notifies all insurance companies of admissions and submits clinicals within the requested time frame. 
• Initiates nursing home placement for patients as indicated. Completes DMA6 and Level 1 PASSR to be provided to accepting nursing homes. Communicates with nursing homes regarding bed availability and where the patient will be transferred to. 
• Obtains insurance precertification on ancillary tests done while in observation (OBS) or inpatient status.
• Responsible for the initiation, ongoing, and completion of physician certification for Swing Bed. Scans all Swing Bed required documents into PCC and sends insurance updates for Swing Bed as indicated by insurance companies.
• Participates in interdisciplinary team meetings with all therapies involved for Swing Bed patients receiving skilled services.
• Informs the patient/family of the patient’s rights and responsibilities, Admission Agreement, Permission to Bill Medicare, and MSP Questionnaire when admitted to Swing Bed and have the above documents signed by patient and/or family member along with a copy of the patient rights. 
• Communicates with the provider when a peer-to-peer is required by an insurance company and sets up the phone call.
• Documents correspondence with insurance companies pertaining to each individual’s progression through Appling Healthcare (inpatient, OBS, testing, admission notification, reviews, etc.).
• Works with admissions clerk, medical staff, and nursing staff to ensure that all patients are in the appropriate service category so records can be coded appropriately. 
• Enters denials, authorizations, and admission reviews into Meditech.
• Takes call rotations.
• Participates in and contributes to interdisciplinary rounds daily.
• Assists in maintaining monthly records of Cost Management (C.M.) activities in appropriate files.
• Acts as an active member of the Utilization Management (U.M.) Committee.
• Assists with the Peer Review Committee.
• Performs other job-related duties as requested.

JOB QUALIFICATIONS

Education/Qualification Requirements:

1. Current RN or LPN license in the State of Georgia.
2. BLS Certification. (Must obtain within 90 days of hire).

Experience:

1. Previous experience in nursing and care/utilization management is preferred but not required. 

Language Skills:

1. Ability to read and communicate effectively in English, both verbally and in writing.
2. Additional languages preferred.

EOE STATEMENT

We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.