- Location
- Remote, US
- Workplace
- Remote
- Department
- Healthcare
- Closing date
- Today
- Source
- iCIMS
Description
Department Overview
The Utilization Management Department enacts the hospital UR Plan. The department provides for the assessment of the medical necessity of admission and continued stay, appropriate bed status, denials management, and outlier review. The department provides clinical information to third party payers to assure medical necessity requirements are met to secure authorization.
Function/Duties of Position
Utilization Nurse Role:
Utilization Management Nurses work within the multidisciplinary team to determine medical necessity of admission and continued stay in the hospital as well as correct patient classification and efficient use of resources. They conduct robust utilization review. Utilization Management Nurses use established criteria to determine appropriateness of admission and continued stay and work with payers to assure ongoing authorization for continued stay. They contribute to meeting OHSU’s strategic plan of safe LOS reduction and reduction in readmission rates.
Patient populations served:• Utilization Management functions are also contracted out to our collaborative site at Columbia Memorial (CMH), Adventist Health (AHPL), and Hillsboro Medical Center (HMC).• Utilization Management completes admission and concurrent reviews on all hospitalized patients regardless of payer, age, or location of admission. They are available to assist in utilization management questions for patients in outpatient spaces and will complete pre-reviews for specific surgical types/locations as consulted.
Skill mix: identify minimum qualifications and competencies necessary to work within department:• The UM functions have been delegated from the Clinical Resource Management Committee (CRMC) by the facilities’ professional board and the activities of the department are reported up through the Regulatory Oversight Committee (ROC). • The Utilization Management department is comprised of primarily registered nurses who hold previous Utilization Management experiences that qualify them for the role. • A physician advisor of UM will also assist with reviewing the utilization of clinical care as well as level of care. The UM physician advisor is used in processes as outlined by the UR plan and acts as the chair of the CRMC committee. • Administrative staff also assist in the performance and evaluation of the Utilization Management activities by designing and implementing systems to enhance data collection and facilitate record review.
Core staffing and methods for determining and modifying staffing to meet patient or process needs:• Assignments are established daily by the UM charge RN to ensure coverage of OHSU hospital units as well as contractual collaborative sites such as AHPL, CMH, and HMC.
Description of assessment and reassessment practices, including timeframes:• Admissions are reviewed within one business day by an UM RN who will screen on the necessity of the admission based on the designated screening criteria. • Concurrent reviews are completed by the UM RN every three days or sooner, when consulted, to evaluate the continue medical need for the patient in a hospitalized level of care. They will collaborate with the care management team and/or UM physician advisor when it is determined that the patient is no longer meeting an acute hospital level of care. • If admission or continued stay is deemed to not be medically necessary, the UM RN will work collaboratively with the UM physician advisor and attending provider for review and determination if non-covered service notice is appropriate to be given to the patient. • In accordance with the CMS regulations, outlier reviews are completed at OHSU. A representative of the UM department is present at the outlier reviews to assist in UM needs or additional medical necessity reviews for the team. • Utilization Management RNs also work collaboratively with the PBS and revenue cycle teams to review clinical data for medical necessity denials. They assist in writing appeal letters as well as identification of trends with payers to elevate specifically to those payers or to make change within the UM processes for denial prevention in the future. • The UM team works collaboratively with the physician community on issues related to UM to assist in problem solving, acting as a resource, or to assisting educational efforts. • The UM department functions within the regulations of DNV and CMS as well as the UR plan that has been approved by the hospitals governing body.
• Proficiency in use of Microsoft Officeo Word: create documents or outlines that may include use of tables, bullets, headers, footers, and basic formattingo Excel: ability to create and use basic spreadsheets that do not involve formulas or pivot tables.o Powerpoint: ability to create basic presentations in outline form using approved OHSU graphics• Proficient at creating formal presentations and presenting to groups of medical professionals• Demonstrated proficiency with conflict resolution• Demonstrated proficiency working cooperatively and productively to achieve shared goals as a member of a team. • Excellent written communication skills, including demonstrated ability to compose persuasive and grammatically correct written arguments• Excellent verbal communication skills• Successful experience in a leadership role in the past 10 years (eg: charge nurse, nurse manager, UBNPC chair, group facilitator, hospital-wide committee membership, etc.)• Proficiency within the interdisciplinary team in resolving conflicts, communicating and educating physicians on patient status decisions and other issues related to Utilization Management.• Proficient in use of Interqual or MCG criteria.• Understanding of the CMS rules and regulations.• Ability and willingness to do presentations to groups of physicians and hospital leadership.• Demonstrated ability to work independently with a minimum of supervision while meeting performance targets.
Department Specific Working Conditions: Utilization Management follows patients on every inpatient, observation, and overnight day stay unit and the Emergency department. Some work occurs in support of procedural areas as well.Each Utilization Management Nurse has access to a computer work station as this is a teleworking position. There is heavy frequent use of computers and telephones.
