What are the responsibilities and job description for the UTILIZATION REVIEW/DISCHARGE PLANNING RN position at Steele Memorial?
The Utilization Review Nurse has well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. This individual leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. This individual maintains current and accurate knowledge regarding commercial and government payers and state and federal regulations/guidelines/criteria related to UM. This role is responsible for ensuring that the UM program maintains documented, up-to-date policies and procedures and ensures and that all UM key processes have valid outcome measures that are monitored for compliance and reported to a variety of audiences. The UR Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly-changing regulatory environment. The UR Nurse is a member of and provides support to the hospital’s UR Committee. He/she collaborates with multiple leaders at various levels throughout Steele Memorial Medical Center, including directors and practitioners, for the purpose of supporting and improving the UM program.