Utilization Review Nurse

MACON COMMUNITY HOSPITAL Position Description Department Name: Care Management Employee Name: Job Title: Utilization Review Nurse Effective Date: Reports to (Title): Care Management Director Supervises: (Positions) N/A I have reviewed these job requirements and verify that I can perform all essential functions of this position. I understand that information regarding patients at this facility is confidential and is not to be disclosed without written authorization of the patient or authorized representative. I will discuss patient’s information only in the course of my duties and never in open areas such as hallways, snack bar, etc., where it might be overheard by visitors or other patients, or outside of the hospital while off duty. I also understand that information in some patient’s records may be governed by federal regulation and that disclosure of such information is punishable by fine or imprisonment, even after I leave the employment of the facility. I certify that I have completed HIPAA training and will honor all policies and procedures. I understand that violations of these policies and procedures may result in sanctions. I agree to abide by all local, state and federal laws. Employee Signature Date: Position Summary Utilization Review : Works collaboratively with interdisciplinary staff internal and external to the organization. Participates in performance improvement and evaluation processes. Performs admission and continued stay reviews utilizing appropriate criteria and guidelines. Participates actively in appeals and denials processes. Interacts with patients/families to identify needed support and referrals to appropriate outside organizations. Implements timely discharge processes. Collaborates in the development of clinical pathways and other protocols. Works closely with nursing service to support and provide care when needed with Med/Surg Supervisor acting as consultant on clinical issues. Utilization Review Nurse, (1) evaluates the appropriateness of admissions to the hospital, treatment rendered, length of stay, use of medical and hospital services and all related factors which may contribute to the effective utilization of hospital and physician’s services, (2) analyzes how utilization of hospital services affects the quality of patient care provided at the hospital, (3) assists with the assurance of proper continuity of care upon discharge and in conjunction with discharge planning, (4) endeavors to assure appropriate allocation of the hospital’s resources by striving to provide quality patient care in the most cost effective manner. Assume the responsibilities of the Social Services/Discharge Planning Coordinator when necessary. Other: This position also coordinates the Peer Review function. II. Position Requirements: Licensure/Certification/Registration: Certification preferred in Case Management. Current registered nursing license in the State of Tennessee.…