RN Utilization Review Specialist Priority Health

Scope of work

Provides health information, interacts, and acts as a resource for providers for complex clinical situations to ensure appropriate use of preservice and concurrent acute medical and/or behavioral health care services. Assesses appropriateness of preservice and concurrent requests for admissions and continued stay. Educates medical staff/other health care professionals regarding utilization management and quality requirements.

Makes recommendations and provides financial and utilization management (UM) information to other members of the care facilitation teams for work prioritization. Works closely with inpatient care facilitators, Medical Social Workers, home health agencies, and providers to move patients through the continuum appropriately. Medical necessity reviews for designated services are completed for all Priority Health plans.

Assesses and interprets clinical information and assists in case management of complex patient population, through use of independent judgment, mature problem solving skills, and guidelines for appropriateness of acute care setting upon admission and continued stay.

Ensure documentation and processes are consistent with regulatory standards

Communicates with physicians, medical social workers, and other hospital personnel concerning change in level of care on the medically complex patient population. Makes recommendations and discusses alternatives. Provides financial/DRG, UM, health information to other facilitation team members for work prioritization. Communicates and collaborates with physicians and members of the team to ensure continuity and coordination of services.

Documents any instances where services were delayed, inappropriate, refused, complicated, etc. for resource management functions.

Identifies quality indicators to facilitate process improvement and physician education.

Ensure members are authorized for the most appropriate level of care and services based on internal and external guidelines.

Collaborates with Medical Directors

Qualifications

• Required Bachelor's Degree or equivalent Nursing or a health care related field; 2 years of relevant experience acute care, clinical nursing, preferably multiple clinical settings, or related experience Required
• 5 years of relevant experience Skills/knowledge/abilities typically gained through at least five years, post licensure, related experience in acute care, multiple clinical settings or behavioral health with utilization management ,discharge planning designing patient centered care plan or related work Required
• Registered Nurse (RN) - State of Michigan Upon Hire required
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