Entry Level Utilization Review Nurse Jobs in Reno, NV

Position Purpose
A clinical position that works within a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options of care, services and alternative levels of care to meet an individual's needs and facilitate appropriate discharge and length of stay. By assuming a leadership role with the interdisciplinary team, the Case Manager promotes appropriate utilization of care and services, and cost effective outcomes. The Case Manager is responsible for the review of the medical record to ensure care and services are delivered timely and appropriately. This position is responsible to reduce and/or eliminate avoidable days.
Nature and Scope
This position has the responsibility to promote case management activities through the health continuum. Case Management starts in the pre-acute phase and continues through the healthcare continuum. Case management begins with the assessment of premorbid health status, current medical condition and post-acute needs. The Case Manager also fulfills Utilization Management responsibilities, including initial UR assessment within 24 hours of admission and concurrent continued stay reviews, ensuring that services are being delivered at the most appropriate level of care to meet the client's needs and to secure reimbursement from payers.
Utilizing an interdisciplinary team approach, this position acts as a consultant and educator on matters referring to alternative levels of care and managed care issues. Through collaboration, case managers provide optimal patient care through, assessment, planning, implementation, and evaluation of neonatal, pediatric, adolescent, adult, and geriatric patients and families . This position also provides information such as certified LOS and reimbursement issues to physicians as needed to ensure the appropriate and timely disposition of the client to the next level of care. The Case Manager monitors and documents the progress of the plan, making revisions as needed, to assure a smooth transition to the next level of care at the time of discharge.
Specifics of Position:
• Excellent documentation and communication skills and must be able to use critical thinking, find solutions quickly and be comfortable escalating when services or care are not delivered efficiently or appropriately.
• Initial assessment on patients with a CM Consult within 24 hours of admission to include identification of anticipated post-acute needs and potential barriers.
• Participate in IDDRs presenting GMLOS, ALOS, anticipated discharge plan, and discharge barriers
• Drive progression of care utilizing evidence based clinical guidelines (i.e., InterQual)
• Facilitate a discharge plan based on clinical needs and resources (e.g., wound vac)
• Ensures post-acute referrals are entered in EMR
• Discharge plan is in place and documented in EMR
• Choice forms are obtained as needed
• IMMs are signed 48 hours prior to DC
• Ensures all are in agreement with discharge plan, date of discharge, and plan for care transitions
• Reviews EMR and ensures when appropriate:
• DME orders entered and Face to Face documentation (as applicable) is done
• DC summaries are written and in system in time for discharge
• All tests are scheduled timely and escalate as needed (Lab, Imaging, Surgery)
• LOS does not extend beyond calculated GMLOS and ensure everyone on care team is working towards timely discharge.
• Clinically complex cases are worked up appropriately for discharge needs (wound vac, IV meds, Meds Requiring Pre Approval, etc.)
• Incumbent must respect beliefs and values while advocating for the client's right to self-determination and to make informed choices.
• Incumbent documents all chart and phone reviews, identifies, documents, and communicates potentially avoidable/non-reimbursed days, and quality indicators (such as re-admissions).,
• Delivers non-coverage letters as set forth by payer and/or regulatory compliance.
• This position acquires and maintains knowledge and competencies related to the expectations of their position including an extensive knowledge of post-acute admission criteria (Rehab, LTAC and SNF etc.). Practice is aligned with the mission, vision and goals of the Integrated Health System. She/he participates in Quality Improvement initiatives.
This position does not provide patient care.
Disclaimer
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications
Requirements - Required and/or Preferred
Name
Description
Education:
Must have working-level knowledge of the English language, including reading, writing and speaking English. Appropriate education to obtain and maintain State of Nevada Registered Nurse licensure. Bachelor of Science in Nursing preferred.
Experience:
One year experience preferred as an RN. Case Management, Post-Acute experience and/or UR/QA experience preferred.
License(s):
Ability to obtain and maintain a State of Nevada Registered Nurse license.
Certification(s):
National Certification in Case Management (CCM) or Accredited Case Manager (ACM) Certification preferred.
Computer / Typing:
Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Teams, Excel, and Word. Must have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.