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Utilization Review Nurse
The Utilization Review (UR) Nurse is responsible for developing and maintaining effective and efficient processes for determining the appropriate admission status and outpatient resource utilization based on reimbursement requirements of various commercial and government payers. The UR Nurse is responsible for performing a variety of concurrent and retrospective UR-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. The incumbent serves as a resource for physicians and other clinical staff for consultation and training purposes. And finally, the UR nurse is a member and coordinator of the Utilization Review Committee.
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- Develop and maintain UR program scope of work, policies and procedures and forms.
- Work with physicians, nurses and payers to ensure that all inpatient admissions are medically necessary, and that the patient’s stay is authorized, and proper paperwork is in place.
- Monitor inpatient length of stay to ensure compliance with hospital policies and payer’s requirements.
- Review outpatient resource utilization and identify appropriateness of rendered services.
- Assist in the monitoring of Operating Room utilization.
- Collaborate with nursing, physicians, finance and medical records to answer clinical questions related to medical necessity and patient status.
- Perform concurrent and retrospective reviews on all admissions and selected outpatient encounters.
- Report variances to the respective physicians and departments upon discovery.
- Serve as a resource person for physicians and nurses to ensure consistent and accurate patient status determinations for appropriate billing purposes.
- Liaise with finance department concerning reimbursement changes and fiscal policies affection patient care.
- Respond to all requests appropriately, accurately, and timely according to Coordinated Care Department guidelines.
- Interact with physicians, nurses, and other hospital colleagues in a timely, positive manner to resolve UR and patient status issues.
- Seek consultation from appropriate disciplines/departments as required to expedite care and facilitate timely and accurate documentation of patient status and clinical reviews.
- Collect and analyze UR data and report findings to the hospital leadership and UR Committee.
- Create reports, displaying data and providing narrative analysis, to a variety of audiences.
- Identify opportunities for process and system improvement and initiate and lead performance initiatives as indicated.
- Create clinical case summaries from a variety of medical record documentation for internal and external audiences, including Ministry of Health (MoH) and insurance representatives.
- Support medical necessity by ensuring that clinical documentation is entered in a clear, concise, organized, and timely manner.
- Respond to all inquiries from payers (MoH, insurance companies and patients) in a timely and professional manner.
- Apply advanced critical thinking and conflict resolution skills using creative approaches.
- Demonstrate a working knowledge of reimbursement requirements and rules and regulations.
- Provide ongoing education to clinical and administrative staff on payment and reimbursement rules and regulations.
- Communicate to the respective staff and departments changes to payment and reimbursement policies.
- Adhere to hospital’s policies and procedures.
- Perform other duties as assigned by managers and hospital leadership.
Education and Experience:
- Bachelor’s degree in Nursing; Master’s preferred.
- At least 5 years experience in a hospital setting in different departments.
Required Skills and abilities:
- Excellent interpersonal communication, problem-solving, and conflict resolution skills.
- Demonstrated flexibility in completing work requirements.
- Strong knowledge of disease and care resource requirements.
- Strong computer skills in using Microsoft Office products.
- Strong analytic skills.
- Ability to work under stress, both with and without supervision;
- Attention to detail and a tolerance for handling a heavy workload.
- Knowledge of healthcare reimbursement systems.
Interested and Qualified candidates are kindly requested to fill the application No later than 7 April, 2021