The RN Utilization Specialist reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
The RN Utilization Specialist (RNUS) is an experienced registered professional nurse with extensive knowledge of patient care, medical treatments, hospital procedures and has expertise in hospital utilization. The RNUS through regular reviews and audits and collaboration with the clinical team, facilitates responsible decisions that promote cost effective health care services as evidenced by appropriate level of care assignment and medical necessity documentation consistent with the patient’s clinical state and intervention plan. The RNUS is a key member of the health care team and as such collaborates with clinicians, responsible for patient care plans, to provide hospital health care benefit coverage information and assist the patients in decisions based on benefits and limitations of coverage plans. The RNUS acts as a change agent to systematically drive change in utilization practices as prioritized by departmental and clinical leadership. As such, the RNUS participates in performance improvement initiatives, implements work process changes, monitors performance, and facilitates necessary changes, under the purview of the Department leadership and in collaboration with practicing clinicians, based on data trends.
Responsibilities:
RN Utilization Review:
- Applies medical necessity screening criteria, level of care guidelines, and professional nursing knowledge to ensure that admissions & length of stay are appropriate
- Completes initial admission and thereafter continuing stay reviews for all hospitalized patients
- Facilitates utilization review concurrent with decisions on hospitalization and may perform duties in the Emergency Department, pre and post-operative, labor and delivery, external transfer, bed assignment, and / or other access points for hospitalization.
- Collaborates with the Payor Specialists and third party payors to effectively communicate all relevant clinical information based on clinical indicators and the plan of care
- Acts as a liaison with the clinical care team assuring compliance with managed care contracts and payor guidelines while maintaining quality of care
- Partners with operational and medical leadership to identify, develop and implement utilization processes that foster the right care at the right time in the right setting.
- Monitors data elements inherently related to Utilization through data reporting tools.
- Effectively resolves utilization dilemmas and as needed uses available escalation pathways (Utilization Medical Director (s) or the Lead Utilization Specialists) to secure further information or expertise to resolve identified issues.
- Makes appropriate referrals to internal physician advisors and contracted third party review company per Department guidelines.
- May participate in interdisciplinary discharge planning rounds to facilitate communication with the care team on documentation and orders necessary to assign accurate medical necessity, level of care, and communication with the payor.
- Interfaces with patients as appropriate to provide education on level of care
- Increases stakeholder understanding of best practices in utilization and internal performance against benchmarks, through a variety of educational forums
- Develops, coordinates, presents, and participates in service-line and clinician education programs.
- Utilizes standardized reports (metrics/dashboard) and provides updates for physicians and the interdisciplinary team members on a regular basis
- Collaborates with the interdisciplinary team to promote the resolution of barriers related to utilization of services and institute changes that improve systems and promote optimal utilization practices
- May assist in the reporting of financial indicators including length of stay, resource utilization, denials and appeals
- Participates in the development, implementation, evaluation and revision of quality utilization tools in collaboration with the healthcare team
- Assists in Recovery Audit Contractor (RAC) and other audit follow up and contributes to appeals on insurance denials as requested.
Additional Functions:
- Maintains current knowledge of federal and state laws and regulations related to utilization
- Actively participates on departmental and hospital committees and taskforces as assigned
- Complies with Northwestern Medicine policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct
- Facilitates review of high risk cases by the Office of General Counsel, Corporate Compliance and Integrity, Risk Management and informs appropriate members of the healthcare team as to interventions. Coordinates interventions in collaboration with the healthcare team
- Participates in hospital and department quality improvement initiatives.