Utilization Review, RN

MedCost excels at helping businesses provide quality health care in a way their company and its employees can afford. Joining MedCost means working alongside enthusiastic, customer-focused teams—people who seek innovative solutions and are passionate about delivering exceptional results. That's why we are committed to investing in individuals and our thriving professional culture. Our work environment is built on appreciation and flexibility, personal and professional growth opportunities, and competitive compensation and benefits.

The major function of the Utilization Review Nurse is to collect medical information regarding inpatient admissions and outpatient procedures/services. Information is used to determine medical necessity of the admission/procedure/service, determine length of stay, and determine the appropriateness of the level of service. Steerage will be made to network providers and medical necessity will be determined for lower-level care. The Utilization Review Nurse is responsible for referring cases that could benefit from discharge planning, transitional case management, personal care management or other continuum programs in accordance with individual health plan provisions.

Answer incoming phone calls, review and enter clinical from EMRs and faxes promptly. Review assigned computer files for each reported inpatient admission and select outpatient procedures/services. Contact attending/ordering physician's office or hospital utilization review to gather relevant medical information based on available criteria to include but not limited to: patient's presenting symptoms, diagnosis, treatment, office or progress notes, labs/test results and/or estimated length of stay. Document all calls or contacts made, and information collected in patient's computer file for the admission or requested service(s). Certify according to criteria if medical necessity is determined. Request physician or pharmacist review if questioning medical necessity. Follow each certified admission on the day prior to discharge for concurrent review, either closing file or contacting medical resource for reason for extended stay. Screen patient file and refer per clinical documentation and guidelines to the appropriate care management program: Case Management for complex needs, Transitional care for discharge planning or Personal Care Management for chronic disease coaching or prenatal program participation for education and nursing support. Keep contact informed about potential noncertification. Explain expedited and standard appeals processes. Document and report caller complaints and quality of care issues. Facilitate discharge planning by providing steerage to network providers. Any special projects or duties as may be assigned by the Manager of Utilization Review.