The RN Utilization Coordinator is a professional registered nurse with expert knowledge in utilization criteria and regulatory documentation requirements. S/he functions across the healthcare continuum, interfacing with professionals from a multitude of disciplines to facilitate the best possible clinical outcomes and optimum level of wellness in the most resources-appropriate manner. Requirements of the job may include cross coverage to utilization review/ care coordination. Cross coverage will include training to the new area and will give the employee additional knowledge and experience within the department. The employee will be proficient in both areas and will work in both areas as needed within budgeted hours.
ResponsibilitiesClinical Knowledge and Interpersonal Skills
* Determines and submits secondary level reviews to Executive Health Resources or the physician advisor as appropriate.
* Possesses skills to perform extensive assessment, development, implementation of care, and collaboration with care coordinators for discharge planning.
* Demonstrates the ability to work with families and groups as is required to provide supportive services.
* Possesses knowledge of advanced medical terminology and conditions in support of hospital treatment.
* Provides education and interacts with hospital staff associated with admission status.
* Provides education to the physicians and staff regarding appropriate level of care/ utilization issues.
* Possesses knowledge or admission criteria for inpatient and observation status criteria.
* Directs, plans, coordinates and oversees specific functions and activities associated with initial admission status determinations.
Documentation and Insurance Provider Knowledge
* Completes and submits requested patient reviews to insurance companies; Ensures that the information submitted is accurate and necessary for review.
* Ensures that second level reviews contain accurate and necessary information.
* Maintains and submits requested documentation as requested by payors.
* Interfaces with Care Coordinator to stay current on discharge plan.
* Understands CMS requirements and Readmission penalties.
* Identifies and records episodes of avoidable delays due to the failure of the progression of care process.
Computer Program Integrity
* Demonstrates knowledge and use of Cerner for daily patient chart reviews.
* Demonstrates knowledge and use of Interqual for primary patient admission status reviews.
* Demonstrates knowledge and use of Executive Health Resources for secondary level admission reviews.
* Maintains appropriate documentation to include specifics related to planning and coordination of patient activities.
Education to Clients
* Possesses confidence in making phone calls to physicians regarding initial or secondary level of admission status.
* Appropriately refers to UR physician advisor for secondary level review.
* Appropriately submits Admission Status cases to be reviewed by the physician advisor.
* Possesses knowledge/comprehends consultative disciplines and the application to patient care.
* Demonstrates ability to work with families and groups as is required to provide supportive services.
* Demonstrates the ability to communicate with physicians and staff regarding appropriate level of care/ utilization issues.
Compliance/Safety
* Responsible for reporting any safety related incident in a timely fashion through the Midas/RDE tool; attends all safety related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.
* Stays current and complies with state and federal regulations/statutes and company policies that impact the employees area of responsibility.
* If required for position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
* Completes all company mandatory modules and required job specific training in the specified time frame.
QualificationsEducation
Graduate from an accredited School of Nursing- Required
Certification & Licensures
Current unrestricted RN license within the state of Arizona- Required
National certification in relevant area of study- Preferred
Experience
3 - 5 years of Med-Surg or Critical Care experience- Preferred
Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.
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