Utilization Review Educator - Registered Nurse at Rochester Regional Health – ROCHESTER, New York

Job Title: Utilization Review Educator - Registered Nurse

Department: Physician Advisor Program -Utilization Review

Location: Rochester General Hospital

Hours Per Week: 40 Full Time

Schedule: Days - M-F

SUMMARY:

Comprehensively plans with the health care team to ensure patient needs are met and care delivery is coordinated across the continuum. Identifies and works to eliminate/minimize system variation and service delivery barriers that prevent achievement of optimal patient outcomes in the expected time frame and with most efficient utilization of resources. Carries out activities related to utilization review. Performs as an integral part of the interdisciplinary team promoting interdisciplinary collaboration and champions service excellence. Facilitates assignment of level of care, considers payer requirements and responds accordingly to avoid adverse financial consequence to patient and hospital. Provide superior customer service by modeling the Brand Promise and Core Values.

RESPONSIBILITIES:

• Conducts clinical reviews utilizing nationally recognized standards of care guidelines to evaluate hospital admissions and assigns patient to the appropriate level of care; identifies clinical resources required to achieve optimal patient outcomes and appropriate reimbursement for the hospital.

• Documents level of care and medical necessity concurrently in the patient’s chart to support the clinical review process.

• Concurrently monitors resources utilization, performing continued stay reviews and assists with managing the length of stay of patients across the continuum.

• Appropriately identifies and refers cases to the Physician Advisor to validate level of care based on medical necessity to support timely progress of patients along the continuum.

• Concurrently communicates clinical information to payors; severity of illness, intensity of service and plan of care.

• Functions as a resource to members of the health care team for payor requirements, ensuring optimal use of patient health care benefits.

• Maintains current and accurate knowledge regarding commercial and government payors and facilitates communication between hospital and payors as appropriate.

• Proactively participates in process improvement initiatives with the use of data, trends and reports, working with a variety of departments and multi-disciplinary staff.

• Works with Utilization Leadership to identify potential problems, recommend solutions and work toward resolution.

• Collaborates with nursing, physicians, admissions, verification team, care management, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status

• Assists in identifying and providing orientation, training, and competency development for Utilization Review RNs on an ongoing basis

REQUIRED QUALIFICATIONS:

• Required Degree: Diploma or Associate’s Degree in Nursing

• Required Certification/Licensure: Licensed in New York State as a Registered Nurse

PREFERRED QUALIFICATIONS:

• Minimum five (5) to eight (8) years clinical experience; utilization management/review experience

• Bachelor’s Degree in Nursing from an accredited school

• Ability to easily navigate Epic EMR

PHYSICAL REQUIREMENTS: M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

PAY RANGE: $86,528.00 - $118,976.00

The listed base pay range is a good faith representation of current potential base pay for successful applicants. It may be modified in the future. Pay is determined by factors including experience, clinical licensure date, relevant qualifications, specialty, internal equity, location, and contracts.