Utilization Review RN

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings.

This will be a remote position. Responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes. Collaborates with facility RN Care Coordinators to ensure progression of care. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status. Communicates the need for proper notifications and education in alignment with status changes. Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention. Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate. Establishes and documents a working DRG on each assigned patient at the time of initial review as directed. Demonstrates behavior that aligns with the Mission and Core Values of the Organization. Responsible for completing required education within established timeframes. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice. Participates regularly in performance improvement teams and programs as necessary. Demonstrates behavior that aligns with the Mission and Core Values of the Organization. Responsible for completing required education within established timeframes. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.