- Department: Utilization Review and Discharge Planning
- Day Shift
- Bachelors degree is preferred
- Licensure Required
- Salary Range: Grade 36 $24.95 Pay will commensurate with experience
Performs admission and concurrent clinical review of medical records for all bedded inpatients and outpatients according to established criteria, policies and procedures and standards of practice to determine appropriate level of care and utilization of resources. Performs utilization review in accordance with all regulatory, state and federally mandated regulations. Reviews and follows up on variances to established criteria, policies, procedures and regulations inclusive of making appropriate referrals for action/resolution. Reviews patient records concurrently to determine the appropriate DRG (Diagnoses Related Group) and the associated geometric mean length of stay. Enters GMLOS into Patient Bed Management System and updates as appropriate. Queries physicians, as needed, for clarification in documentation. Educates providers, on a case-by-case basis, including physicians on appropriate and/or alternate care setting, reimbursement issues, UM regulatory and payer requirements. Follows up with payers, as needed to respond to requests for additional clinical information and discharge plans. With both initial and concurrent reviews, assesses patients for potential post-discharge home care needs and placements and makes referrals to discharge planners. Identifies service delays through review of patient records and communicates these and other issues impacting timely and efficient progression of care to Unit Clinical Care Coordinator for follow-up. Service and care delays are loaded into Maxsys for monitoring and trending by designated staff. Works collaboratively with Discharge Planning, Care Coordination and other disciplines involved in the patient’s care plan and care pathway to facilitate safe, efficient and timely progression of care and discharge.
Experience: Three years of acute care nursing experience. Utilization management, utilization review or case management experience in health care setting is highly preferred.
Certification/License/Registration: Must be licensed as a Registered Nurse in the State of Georgia.