Utilization Review RN Per DiemWork Shift: Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses, and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.
Position Overview: Performs chart review of identified patients to identify quality, timeliness, and appropriateness of patient care.Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self-pay patients, based on appropriate guidelines.Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis.Confers proactively with admitting physician to provide coaching on accurate level of care determinations at the point of hospital entry.Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services.Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters.Identifies and records consistently any information on any progression of care or patient flow barriers.Consults with medical staff, care team, and case managers as necessary to resolve immediate progression of care barriers.Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources.Recognizes and responds appropriately to patient safety and risk factors.Represents Utilization Management at various committees, professional organizations, and physician groups as needed.Promotes the use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care.Identifies, develops, and implements strategies to reduce lengths of stay and resource consumption in the patient population.Participates in performance improvement activities.Promotes medical documentation that accurately reflects findings and interventions.Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes.Maintains appropriate documentation in the Utilization software system on each patient.Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports.Identifies potentially wasteful or misused resources and recommends alternatives if appropriate.Maintains related continuing education credits = 15 per calendar year.MINIMUM REQUIREMENTSEducation: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred.Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience.Other Credentials: Registered Nurse - NJKnowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred.Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines.Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.Usual Work Day: 8 HoursPHYSICAL DEMANDS AND WORK ENVIRONMENTFrequent physical demands include: Sitting, Standing, WalkingOccasional physical demands include: Climbing, Carrying objects, Pushing/Pulling, Twisting, Bending, Reaching forward, Reaching overhead, Keyboard use/repetitive motion, Talking or HearingContinuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs.Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate HearingAnticipated Occupational Exposure Risks Include the following: N/AOffers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants (including contractors, travelers, and consultants) to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.
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