RN Utilization Management Initial Review-Full Time and Part Time Days & Nights-Onsite Position

• Completes initial and concurrent reviews on all patients who occupy a bed. Assesses patient records as assigned for medical necessity utilizing Medicare's Two Midnight Rule & MCG guidelines as review criteria. Accurately documents justification for level of care within the review citing specific clinical information as necessary. Ensures physician order is appropriate for the documented level of care. Documents avoidable days in the electronic health record as appropriate.
• Accurately manages authorizations for acute medical services for assigned cases and ensures the correct level of care is reflected in the authorization requested. Responds to requests for clinical in a timely manner, ensuring no denials for Lack of Information are received. Collaborates with Insurance Verification department to communicate changes in level of care and coverage. Ensures all concurrent denials are addressed in a timely manner, communicating with the Physician Advisor and Attending Provider as necessary. Documents appropriately in the electronic medical record.
• Manages all denials concurrently. Collaborates with the Physician Advisors and Attending Providers to ensure compliance with issues relevant to non-coverage/possible denials. Assists in the scheduling of peer to peer discussions and relays this information to the appropriate provider. Accurately documents all information in the electronic medical record and documents outcomes and steps for next level of appeal as necessary.
• Maintains knowledge and understanding of Medicare/Medicaid regulatory requirements and Conditions of Participation. Completes quarterly verification of competency via assigned MCG Interrater Reliability cases and actively participates in review discussions.
• Collaborates openly with Physician Advisors when seeking guidance on level of care determinations, peer to peer discussions, and denial management. Accurately documents all referrals in the electronic medical record to ensure accurate capture data.
• Openly communicates with Care Coordinators to include notification of avoidable days, changes in level of care, denials of authorization, and changes in coverage, etc. Documents this notification in the electronic medical record.

• Program Graduate, Professional Nursing (Required)
• Bachelors Degree, Nursing (Preferred)

• 3-4 years Clinical nursing experience (Required)

• Registered Nurse (RN) - State Department of Health Professions (Required)

Riverside Health System