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Utilization Review Nurse Specialist job in Nashville at Nashville General Hospital

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Utilization Review Nurse Specialist at Nashville General Hospital

Utilization Review Nurse Specialist

Nashville General Hospital Nashville, TN (On Site) Full-Time

DescriptionThe Utilization Review (UR) Specialist has well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. Responsible to ensure that health care services are administered with quality, cost efficiency, and within compliance, along with improving and ensuring the overall quality, cost efficiency and completeness of documentation within the inpatient medical record. Continuously reviewing and auditing patient medical records (observation and inpatients), screening for unnecessary procedures, ineffective treatments, and unnecessarily extensive hospital stays. Educates members of the patient care team on documentation guidelines on an ongoing basis. Facilitates modifications to clinical documentation through extensive concurrent interaction with physician and other members of the healthcare team to support the appropriate reimbursement and clinical severity are captured compliantly for the level of service rendered to all patients.EducationAssociates RequiredBachelors PreferredCertification & LicensuresActive Tennessee RN licenseExperience3 years Healthcare/Medical - Acute Care Required2 years Healthcare/Medical - Case Manager PreferredAdditional experience requirementsKnowledge of statistical processes, quality improvement tools, techniques, and analytical skills, with the ability to link quality of care/services to patient satisfaction, financial, and other statistical data is preferred. Must demonstrate excellent interpersonal skills and be able to effectively educate staff and physicians.Coordinate and facilitate correct identification of patient status.•Collaborate and set standards with registered nurse (RN) case managers (CMs) and physician teamsto ensure that all hospitalized patients have the correct admission status (inpatient, outpatient short stay,observation status) so that the appropriate claim can be submitted to commercial and government payers.•Identify opportunities for process and system improvement initiatives as indicated.•Collaborate with nursing, physicians, admissions, and finance staff to answer clinical questions related to medicalnecessity and patient status.•Maintain current status determination tools and other UM tools and distribute to staff as needed.Coordinate and integrate UM functions.•Ensure that providers are consistently recommending the appropriate admission status in real-time and provideeducation as needed.•Perform other concurrent and retrospective reviews as directed by Director of Case and Utilization Management.•Prepare succinct, written clinical case summaries that include rationale for the recommended billing statusas directed by Director of Case and Utilization Management•Serve as a resource person for providers and others to ensure consistent and accurate patient statusdeterminations for appropriate claim submission.•Participate in UR Committee and UM activities:•Assist with preparation of discussion and appeal letters for Medicare/Medicaid medical necessitydenials.•Other audit activities as requestedCollaborate with all members of the healthcare team, both internal and external customers.•Provide clinical consultation regarding UM to physicians and other colleagues within the NGH system.•Respond to all requests appropriately, accurately, and timely according to Case and UM Departmentguidelines.•Interact with physicians, nurses, and other hospital colleagues in a timely, positive manner to resolve UMand patient status issues.•Seek consultation from appropriate disciplines/departments as required to expedite care and facilitatetimely and accurate documentation of patient status and clinical reviews.•Refer UM issues to the Director of Case and Utilization Management, and/or UR physician advisor(s) in atimely manner and monitor the issue until it is resolved.Participate in clinical performance improvement activities to achieve set goals.•Use data to drive decisions and plan/implement performance improvement strategies related to UMactivities.•Collect data for the creation of reports, to display UM data and provide narrative analysis, to a variety of audiences.•Participate in development, implementation, teaching, evaluation, and revision of departmental standardsrelated to UM.Demonstrate positive and professional written, verbal and nonverbal communication skills.•Substantiate activity by documentation that is entered in a clear, concise, organized, and timely mannerper NGH documentation guidelines.•Reflect concise clinical pertinence in documentation for assigned patient population.•Respond to all inquiries from payers within a professional manner•Document UM, quality, and risk concerns and refer to appropriate departments as applicable for follow up.•Complete assignments, monthly statistics, and all reports as directed by the Director of Case and Utilization Management•Apply advanced critical thinking and conflict resolution skills using creative approaches.Nashville General Hospital is an Equal Opportunity Employer/Disability/Veteran.We are an E-Verify employer.

For more information, please click on the following links:

E-Verify Participation Poster: English Spanish E-Verify Right to Work Poster: English Spanish

Recommended Skills

  • Utilization Management
  • Managed Care
  • Credentialing
  • Medicare
  • Medical Management
  • Medicaid
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