Utilization Review Nurse

Job Summary:

The Utilization Review RN is responsible for utilization review, discharge planning and transitions in care, in collaboration with MAPMG rounder in acute or alternative settings of care.

Essential Responsibilities:

• Utilization Review. According to department policy, procedure and protocols, consistently apply and verbally communicate approved utilization review criteria and guidelines for services delivered in acute or alternative care settings.
• Eligibility and Benefit Verification. Confirm eligibility status and ensure the appropriate administration of benefits in accordance with department policies and procedures.
• Assessing Right Venue of Care with Hospitalist. Collaboration with Hospitalist to assess the appropriate level of care for patients (i.e., Medical Unit, Surgical Unit, Tele Unit, TCU, ICU) and post- (Home, Continuum or Community-based Services) hospitalization.
• Coordination of Care. Driving patient care plan through assuring daily plan is executed, and management of transitions and post-hospital care.
• Effective Discharge Planning. Prompt, clinically appropriate discharge planning beginning at time of admission.
• Variance Management. Timely steps in identification of delays in throughput, escalation to correct delays, and recording delays to identify patterns and trends that will require corrective actions.
• Quality Screening. Demonstrate competency to assess all aspects of care across the continuum for variations from quality and utilization standards.
• Performs other related duties as directed.