Utilization Review RN

The Utilization Management RN reports directly to Utilization Review RN Coordinator. The UR RN supports the UR RN Coordinator and other UR team members in providing all identified utilization review functions for the organization to ensure cost effective care delivery.

The UR LPN is responsible for completing utilization reviews, referral to MD advisor service(s) to allow for secondary review, contact with providers for notification and to obtain status orders when appropriate; continued stay reviews for cases where admission exceeds the GMLOS, documentation of avoidable, initiation of authorization request and submission of records for post-acute care facilities who are admitting patients from St. Peter's Health. Facilitation of peer to peer calls for both hospital admissions and for specific outpatient service denials as assigned, and participation in the organizations Utilization Review Committee.

In collaboration with the patient/family, physicians, and the interdisciplinary team, the UR RN ensures the care delivery systems at SPH are utilized effectively and efficiently; engages the UR RN Coordinator with improvement ideas when deviations of best practice are noted. The UR RN serves as an advocate for the patient and family throughout the continuum of care and serves as a collaborative and supportive liaison and educator to providers and staff around utilization management principles.

This professional role will be responsible for:

1.    Stay current on insurance issues and proactively educates/notifies UR RN Coordinator of pertinent changes.
2.    Maintain confidentiality of hospital, patient, and family information.
3.    Must be able to interact with various hospital staff and departments at all levels possessing positive communication skills and compassionate competence.
4.    Apply medical knowledge and experience for prior authorization requests.
5.    Perform detailed medical reviews of prior authorization request or assessment forms according to established criteria and protocols.
6.    Manage incoming authorization requests and inquiries via email, fax, computer, telephone, or mail.
7.    Maintain accurate documentation on all requests and documenting in the appropriate computer application.
8.    Initiate and continue direct communication with health care providers involved with the care of the patient to obtain complete and accurate information. 
9.    Follow-up on Peer to Peer requests including scheduling these to be completed between the facility and plan providers.
10.    Review insurance companies' requests for change of patient status using MCG guidelines then negotiates with insurers to obtain the maximum