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RN Utilization Review

Denver, CO, United States

Description

SHIFT: No Weekends

SCHEDULE: Full-time

The Utilization Review RN provides clinical information to insurance companies according to the terms of the contract, receive/seek out authorization/certification for the hospital stay, perform concurrent denials, determine the correct patient status by reviewing medical necessity and communicate this to the facilities, follow the X-code process per HCA policy and maintain communication with the facility case managers.  

 
DUTIES INCLUDE BUT ARE NOT LIMITED TO:
 

This position will focus on initial and continued stay utilization review and denials to include assessment of medical records for appropriateness as well as level of care provided.  A team approach with the facility Case Management department is essential.

 
  • Perform InterQual review within one business day on all inpatient admissions. (Excluding FC 1, 2, 15, 99 (Medicare, self-pay, uninsured/charity) & Mother/Well-Baby). 
  • Document note to support inpatient admission.
  • Review for inpatient admission status order.
  • Ensure the patient’s status is correct in Meditech & MIDAS.
  • Perform continued stay reviews via InterQual application, at a minimum of every 3 days.
  • Review concurrent denials and work with the facility and physician to overturn.
  • Communicate the denial status to the facility and physician.
  • Follow all HCA standards regarding documentation and education.
  • Communicate with physicians regarding patient status.
  • Communicate medical necessity and responder criteria to the facility case managers.
  • Review the Authorization/Certification report daily to determine deficiencies. 
  • Documentation to take place in Midas within the Care Enhancement Review Entry (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable/Denied Days Module.
 
 

HealthONE® is the largest healthcare system in the metro Denver area with more than 10,000 employees. As part of the HealthONE family, The Medical Center of Aurora, North Suburban Medical Center, Presbyterian/St. Luke’s Medical Center, Rocky Mountain Hospital for Children, Rose Medical Center, Sky Ridge Medical Center, Swedish Medical Center, and Spalding Rehabilitation Hospital work together to provide a higher level of care. In addition, our family of services includes seven free-standing emergency departments, numerous ambulatory surgery centers, CareNow Urgent Care Clinics & Occupational Medicine, physician practices, and AIRLIFE-DENVER, which provides critical care air and ground transportation across a 10-state region.


Qualifications

Education
  • BSN, Bachelor of Science in Nursing (preferred)
 
Licensure/Certification
  • Registered Nurse (RN)
 
Experience
  • InterQual (required)
  • Acute care hospital case management/utilization review experience
  • Third party payer experience (helpful)
  • Denials Management (helpful)

Facility: HealthOne
Job ID: 03174-78479
Category: Nursing - Professional
Contract: Full-time
Shift: No Weekends
Job Class: Regular

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