Utilization Review Nurse
Under the direction of the Director of Case Management/Social Work the Utilization Review Nurse works in collaboration with the RN Nurse Case Manager who is ultimately responsible for the care of that patient. The Utilization Review Nurse covers all of the nursing units throughout the hospital so as to ensure that all patients are seen when providing relief for the RN Nurse Case Manager. Furthermore, the case manager complies with and participates in maintaining an atmosphere which supports the SJH values of SPIRIT.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
1. Maintains recognition and acceptance of accountability and responsibility for duties and functions within the scope of the practice of the RN; collaboration with other team members towards problem resolution; precise and appropriate verbal and written communication; and behaviors consistent with the role of the professional nurse.
2. Reviews patient’s medical records to collect data pertaining to diagnoses and major procedures performed, evaluates appropriateness of admission, observation and length of stay, and completes required forms.
3. Reviews patient’s medical records for particular aspects of care (as directed) and/or problems which adversely affect patient care.
4. Performs concurrent reviews of admissions to determine medical necessity for admission, observation and continued stays. Refers those that do not meet criteria to the Physician Advisor and/or Department Chairman.
5. Performs concurrent reviews for the appropriateness of resource consumption and refers any over or under utilization to the Physician Advisor.
6. Reviews specific incidents and utilization problems with Physician Advisor such as extended hospital stays, complications with care, and patients waiting for placement.
7. Conducts ongoing utilization review for compliance with approved third-party treatment plan and ensures necessary interventions. Communicates with payors regarding clinical updates and the need for continued hospitalization.
8. Follows through on the assessment of the RN Case Manager for discharge planning and educational needs in the absence of that case manager; plans the patient’s care and ensures that patient family teaching is complete.
9. Consistently supports the hospital’s Spirit of Serving Standards, in line with the Mission, Vision and values of St. Joseph Medical Center.
10. Supportive of the compliance program set forth by SJMC and demonstrated by:
a. Upholds the Code of Ethics and Corporate Compliance.
b. Adheres to and helps to enforce all compliance policies relevant to his/her area.
c. Assures timely compliance education as requested by the Compliance Officer and/or through corporate initiatives.
11. Sets an example to all staff in their daily activities.
- Prefer two years’ experience as a Clinical Nurse, proficient in clinical and technical skills in nursing specialty; leadership and teaching skills in order to gain a full understanding of case management practices and procedures.
- Current LVN or RN licensure issued by the Board of Nurse Examiners issued by the State of Texas.
EDUCATION & TRAINING:
- Knowledge of patient care treatment, planning and assessment at a level normally acquired through completion of an approved, accredited School of Vocational Nursing program in order to be able to provide patient care or Associates Degree in Nursing from an accredited School of Nursing.