Registered Nurse uses approved screening criteria (Milliman/Interqual/CMS Inpatient List) to determine the medical necessity of a requested hospitalization and the appropriate level of care for that patient. Works collaboratively with Nursing Supervisor for appropriate bed assignment. Actively involved in management of inpatient observation patients. Provides consultative role as utilization management nurse to clinical and non-clinical departments. Documents objective findings against approved indicators. Assists with retrospective reviews and medical necessity denials per communication with third party payors. Follows UM policies and procedures and assists with continually improving the quality and effectiveness of the utilization management program at CSVRMC.
MINIMUM QUALIFICATIONS:
EDUCATION: Graduate of an approved school of nursing, BSN preferred.
CERTIFICATION/LICENSES: Current licensure as an RN in New Mexico mandatory.
SKILLS: Excellent reading, writing, and editing skills in English. Strong organizational skills. Knowledge of or ability to learn Milliman and Interqual criteria. Ability to effectively evaluate physician orders and medical records. Competent computer skills for word processing, data collection and retrieval. Ability to analyze and create reports.
EXPERIENCE: Minimum of five years of experience in a health care setting, of which a minimum of two years has been spent in an acute care setting. Experience with utilization management, knowledge of Milliman and Interqual criteria, managed care language, and CMS rules and regulations preferred.
NATURE OF SUPERVISION:
-Responsible to: Director and Manager of Case Management
ENVIRONMENT: Blood borne Pathogens: A
Office setting. Rotating shifts and weekends when necessary. Must be able to adjust to frequently changing workloads and frequent interruptions.
PHYSICAL REQUIREMENTS:
Ability to move around the hospital to all units/departments for about 10% of the day, in office 90% of the day. Requires close work, good vision, dexterity to write as well as to use computer keyboard. May be required to lift, push, pull and/or carry up to 25 lbs.
