Discharge Planner Utilization Review Jobs (NOW HIRING)

Description
The discharge planning-UR nurse is responsible for coordinating and facilitating patient care across the continuum to ensure safe, timely, and appropriate care that meets regulatory standards, patient goals, and hospital policies. The discharge planning-UR nurse serves as a liaison between patients, families, providers, and interdisciplinary team members, ensuring appropriate utilization of services and effective discharge planning within the hospital. May assist the review committee in planning and performing federally mandated quality assurance reviews.
• Coordinates the transition of patients from inpatient, swing-bed, some post-surgical by referral, and observation levels of care to home, skilled nursing, long-term care, or other post-acute settings. Hospice/Respite patients are handled by the Hospice Department.
• Collaborates with physicians, nursing, therapy, and ancillary services to develop and document individualized discharge plans.
• Assists patients and families in understanding care options, insurance coverage, and available community resources.
• Conducts admission, concurrent, and discharge reviews in compliance with CMS Conditions of Participation, Medicare criteria, and hospital policy.
• Applies approved criteria (InterQual or MCG if available) to determine medical necessity and appropriate level of care.
• Collaborates with providers and Revenue Cycle Manager to resolve medical necessity denials or queries and documents all UR activities timely.
• Participates in internal and external audits related to utilization management.
• Advocates for patient rights and ensures patients and families are included in care decisions.
• Provides education on available services, community supports, and advance care planning.
• Promotes patient self-management and continuity of care after discharge.
• Advocates for patient rights and ensures patients and families are included in care decisions.
• Provides education on available services, community supports, and advance care planning.
• Promotes patient self-management and continuity of care after discharge.
• Maintains accurate and timely documentation (DC and swingbed assessments, SDOH, discharge notes, nursing goals, etc.) in the electronic health record (EHR) for all of the types of patients (inpatient, swing-bed, some post-surgical by referral, and observation).
• Ensures compliance with CMS, Joint Commission, and Idaho Department of Health & Welfare regulations.
• Tracks readmissions, length of stay, and avoidable days for quality improvement reporting.
• Participates in Quality Assurance and Performance Improvement (QAPI) initiatives.
• Identifies trends in utilization, discharge delays, and social barriers to improve patient flow and outcomes.
• Provides data and recommendations to hospital leadership for system improvement.
• Maintains compliance with regulations changes affecting utilization management.
• Reviews patients' records and evaluates patient progress. Performs concurrent and continuing review on medical records and identification and need of on-going hospitalization.
• Notifies payers of inpatient admissions. Obtains authorization and eligibility from patients' insurance for the hospital stay, outpatient surgeries and procedures.
• Completes insurance tracking and notification per specific insurance protocols for payment. Complete retroactive reviews once pay source is established.
• Performs other duties as assigned.
Requirements
• Associates or bachelors degree in nursing.
• Current license to practice nursing in Idaho required.
• 5 years of clinical care or nursing experience preferred.
• 2 years of Utilization Review experience preferred.
• Prior experience with care management preferred.
• Knowledge of nursing principles, techniques, and procedures for the assessment and care of patients, medical terminology anatomy, physiology and concepts of disease.
• Knowledge of Medicare Conditions of Participation, discharge planning and medical necessity criteria.
• Skill with Inter-Qual and Milliman criteria.
• Ability to follow rules and regulations as set forth by the Centers for Medicare Medicaid Services as well as state specific Medicaid.
• Ability to work calmly, professionally and effectively under pressure, handling demands from multiple sources.