RN-Utilization Review (Remote Position - AZ Residents ONLY!)

**Kingman Healthcare Incorporated (KHI)** **Staff Position Description** **Position Title:** Utilization Review Nurse **Position Code:** RN\-6027 **Department:** Case Management **Safety Sensitive:** Yes No **Reports to:** Director of Case Management **Exempt Status:** Yes No **Position Purpose:** All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision to be among the kindest, highest quality health systems in the country. **Key Responsibilities** * Responsible for conducting and coordinating medical necessity reviews for all patients upon admission to inpatient or observation status and complete continued stay reviews throughout the stay. * Evaluates surgical schedule for inpatient only procedures (IPOs) and communicates via message system the need for appropriate orders. * Verifies physician orders in the medical record follow Medicare and other payer guidelines for determining level of care. Assures medical documentation accurately reflects the severity of illness and acuity of the patient. * Communicates with KHI medical staff as needed to reconcile and clarify admit orders and/or medical documentation to ensure that the hospital is reimbursed appropriately for services rendered. * Consults with Physician Advisor as needed to make medical necessity determinations and or make referrals for cases not meeting criteria as per KHI Utilization Management Plan. * Works collaboratively with Case Managers and Insurance Specialist to ensure that appropriate and accurate clinical information is communicated to payers within required timeframes as per KHI policies and procedures. * Responsible for complete, accurate and timely entry of information related to the utilization review process into data systems. Maintains documentation of all activities to support medical necessity determinations. * Collaborates with all members of the healthcare team, the business office, and payers as necessary, to ensure patients receive high quality care in the most cost\-effective manner. * Collaborates with Denials Manager and RAC team to identify issues and/or trends related to medical necessity denials. Participates in the denials management process. * Serves as a resource to Case Management staff and provides education and coaching regarding appropriate use of clinical guidelines, utilization review and payer regulations. * Establishes communications system for days off. Assists in sending admitting and discharge clinicals on all patients * **Review Process:** * Reviews Medical Records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria. * Evaluates medical information against nationally recognized criteria and determines necessity for admission, continued stay, appropriateness of service, and/ or level of care. * Collaborates with the physicians to determine appropriate inpatient versus observation status