Registered Nurse (RN) - Utilization Review
Good Samaritan Regional Medical Center
Corvallis, OR

Utilization Review Nurse

JOB SUMMARY/PURPOSE Reviews hospital admissions for medical necessity and conducts concurrent reviews of all patients regardless of financial class. Responsible for utilization review to ensure correct admission status is ordered and length of stay is appropriate. Provides appropriate information to physicians and healthcare team members related to required documentation elements. Provides patient/family education regarding payer regulations and reimbursement criteria. Documents all clinical reviews in designated computer database utilizing nationally recognized screening criteria. Provides clinical information to payers as allowed by HIPAA. Manages the patient account classifications during a patients stay for accuracy of billing and compliance. Tracks avoidable/denied day information. DEPARTMENT DESCRIPTION The Utilization Management team is a centralized team of physicians, nurses and specialists that perform admission and continued stay compliance reviews for all Samaritan Hospitals. Utilization Management nurses and physicians are specially trained in Medicare and commercial insurance regulations, perform reviews on all admitted patients and provide staff and physician education. The Utilization Management team communicates information to insurance companies to assure payment of hospital services. EXPERIENCE/EDUCATION/QUALIFICATIONS Current unencumbered Oregon Registered Nurse license required. Baccalaureate Degree in Nursing preferred. Three (3) years RN experience required. Experience and/or training in health care, health care delivery systems, managed care and a basic knowledge of utilization review, case management and health information systems required. Experience and/or training in insurance benefits or covered services including Medicare and Medicaid required. Experience and/or training in computer applications required. Typing speed of 35 wpm preferred. Three (3) years hospital nursing experience preferred. Acute care utilization review, discharge planning or case management experience preferred. Utilization Review or Case Management Certification preferred. KNOWLEDGE/SKILLS/ABILITIES Communication - Effective written and oral communication skills to explain complex medical and regulatory issues, exchange information between team members, and tactfully discuss utilization management and compliance concepts. Ability to #listen and understand complex information and ideas. # Business Writing - Strong business writing skills, including the ability to professionally communicate clinical content in written/typed documentation that is easily understood by the end user. Ability to use a computer for required documentation.################### Compliance - Ability to evaluate information to determine compliance with laws, regulations, or standards. Uses clinical and regulatory knowledge to determine compliant process application. # Social Perceptiveness - Ability to work with a diverse population from pediatrics to geriatrics. Basic understanding of age-related differences in caring for and/or communicating with patients and caregivers. Possess personal sensitivity to the needs and experiences of others and a non-judgmental attitude towards persons of differing standards, values, lifestyles, and ages. # Time Management - Ability to organize, plan and prioritize work to complete within required time frames and to follow-up on pending issues. Ability to perform multiple tasks simultaneously and thrive in dynamic fast-paced environments and under pressure. PHYSICAL DEMANDS Rarely (1 - 10% of the time) Occasionally (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 # 100% of the time) CLIMB - STAIRS LIFT (Floor to Waist: 0#-36#) 0 - 20 Lbs LIFT (Floor to Waist: 0#-36#) 20 - 40 Lbs LIFT (Floor to Waist: 0#-36#) 40 - 60 Lbs LIFT (Floor to Waist: 0#-36#) 60 or more Lbs LIFT (Knee to chest: 24#-54#) 0 # 20 Lbs LIFT (Waist to Eye: up to 54#) 0 - 20 Lbs LIFT (Overhead: 54# and above) 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds CARRY 2-handed, 0 - 20 pounds CARRY 2-handed, 20 - 40 pounds SQUAT Static (hold #30 sec) SQUAT Repetitive KNEEL (on knees) REACH - Upward PUSH (0 - 20 pounds force) PULL (0 - 20 pounds force) PUSH (20 - 40 pounds force) PULL (20 - 40 pounds force) STAND WALK # LEVEL SURFACE ROTATE TRUNK Sitting ROTATE TRUNK Standing # BEND FORWARD at waist REACH - Forward PINCH Fingers GRASP Hand/Fist SIT MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY * JOB SUMMARY/PURPOSE * Reviews hospital admissions for medical necessity and conducts concurrent reviews of all patients regardless of financial class. Responsible for utilization review to ensure correct admission status is ordered and length of stay is appropriate. Provides appropriate information to physicians and healthcare team members related to required documentation elements. Provides patient/family education regarding payer regulations and reimbursement criteria. Documents all clinical reviews in designated computer database utilizing nationally recognized screening criteria. Provides clinical information to payers as allowed by HIPAA. Manages the patient account classifications during a patients stay for accuracy of billing and compliance. Tracks avoidable/denied day information. * DEPARTMENT DESCRIPTION * The Utilization Management team is a centralized team of physicians, nurses and specialists that perform admission and continued stay compliance reviews for all Samaritan Hospitals. Utilization Management nurses and physicians are specially trained in Medicare and commercial insurance regulations, perform reviews on all admitted patients and provide staff and physician education. The Utilization Management team communicates information to insurance companies to assure payment of hospital services. * EXPERIENCE/EDUCATION/QUALIFICATIONS * Current unencumbered Oregon Registered Nurse license required. * Baccalaureate Degree in Nursing preferred. * Three (3) years RN experience required. * Experience and/or training in health care, health care delivery systems, managed care and a basic knowledge of utilization review, case management and health information systems required. * Experience and/or training in insurance benefits or covered services including Medicare and Medicaid required. * Experience and/or training in computer applications required. Typing speed of 35 wpm preferred. * Three (3) years hospital nursing experience preferred. * Acute care utilization review, discharge planning or case management experience preferred. * Utilization Review or Case Management Certification preferred. * KNOWLEDGE/SKILLS/ABILITIES * Communication - Effective written and oral communication skills to explain complex medical and regulatory issues, exchange information between team members, and tactfully discuss utilization management and compliance concepts. Ability to listen and understand complex information and ideas. * Business Writing - Strong business writing skills, including the ability to professionally communicate clinical content in written/typed documentation that is easily understood by the end user. Ability to use a computer for required documentation. * Compliance - Ability to evaluate information to determine compliance with laws, regulations, or standards. Uses clinical and regulatory knowledge to determine compliant process application. * Social Perceptiveness - Ability to work with a diverse population from pediatrics to geriatrics. Basic understanding of age-related differences in caring for and/or communicating with patients and caregivers. Possess personal sensitivity to the needs and experiences of others and a non-judgmental attitude towards persons of differing standards, values, lifestyles, and ages. * Time Management - Ability to organize, plan and prioritize work to complete within required time frames and to follow-up on pending issues. Ability to perform multiple tasks simultaneously and thrive in dynamic fast-paced environments and under pressure. * PHYSICAL DEMANDS * Rarely (1 - 10% of the time) Occasionally (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 - 100% of the time) CLIMB - STAIRS LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs LIFT (Floor to Waist: 0"-36") 20 - 40 Lbs LIFT (Floor to Waist: 0"-36") 40 - 60 Lbs LIFT (Floor to Waist: 0"-36") 60 or more Lbs LIFT (Knee to chest: 24"-54") 0 - 20 Lbs LIFT (Waist to Eye: up to 54") 0 - 20 Lbs LIFT (Overhead: 54" and above) 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds CARRY 2-handed, 0 - 20 pounds CARRY 2-handed, 20 - 40 pounds SQUAT Static (hold >30 sec) SQUAT Repetitive KNEEL (on knees) REACH - Upward PUSH (0 - 20 pounds force) PULL (0 - 20 pounds force) PUSH (20 - 40 pounds force) PULL (20 - 40 pounds force) STAND WALK - LEVEL SURFACE ROTATE TRUNK Sitting ROTATE TRUNK Standing BEND FORWARD at waist REACH - Forward PINCH Fingers GRASP Hand/Fist SIT MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY