Position Summary: The Utilization Review (UR) Nurse is primarily responsible for completing admission review on all patients within 24 hours of admission using electronic InterQual tool. The UR nurse complies all pertinent clinical information to ensure the payor has sufficient information to decide to approve or deny services and Tidelands Health Physician Advisor Team have the necessary information available to assist in getting patient in appropriate status for all referrals. The UR nurse works closely with commercial payors and Tidelands Health internal Physician Advisor Team, business office, registration, and CDI team. The UR Nurse is responsible for tracking clinical service utilization of specific patients from admitting to discharge. Tracking includes the concurrent collection of data, and analysis for appropriateness and timing of interventions. The Case Manager provides practical interpretation of the analysis for nurses, multi-disciplinary teams, medical staff and managers as the findings and recommendations relate to the individual patient’s outcomes, the health plan coverage, and the overall costs for both the patient and the hospital.
- Associate Degree in Nursing, required; Bachelor of Science Degree in Nursing, preferred
- Current and in good standing SC RN license with SCLLR.
- Minimum two years RN Utilization Review with Interchange Health, InterQual tool experience in an acute care setting preferred.
- Demonstrates knowledge and experience with Case Management process, hospital revenue cycle, and appeals and denials
- Special Skills:
- Able to work independently, adjust priorities often and establish rapport quickly required
- Demonstrates fluent typing skills.
- Exception critical thinking and problem skills required.
- Able to apply clinical guidelines to assist in medical necessity determinations
- Demonstrated experience in diplomacy and ability to contribute to team goal setting and program development required.
- Demonstrates excellent communication skills, both verbal and written required.
- Basic computer knowledge and skills required to manage multiple databases required.
- Primary home base will be established but flexibility to float to various facilities within the GHS system as needed required.
- Flexibility to cross cover as float discharge planner on as needed basesWhile performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; occasionally (activity or condition exists up to 1/3 of the time) to use hands, fingers; and frequently to talk or hear. The employee must exert 15 to 20 pounds of force occasionally, and/or 5 to 10 pounds of force frequently, and/or greater than negligible up to 5 pounds of force constantly to move objects. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job and will be tested by post offer PAT.
- Physical Requirements: Light-Medium Physical Agility Test Rating (PAT)