Utilization Review Nurse (RN)-PRN
University Heights, OH
Part Time
Nursing
Experienced
Utilization Review Registered Nurse- PRN
ESSENTIAL DUTIES:
- Immediately respond to all Bluestone Intak email, faxes and phone calls.
- Review all referrals for clinical appropriateness within 10 minutes of receipt, except during approved break times.
- Contact the provider on call within 10 minutes of the completed review of the referral.
- Facilitate the admission with the referring hospital, including completing the nurse-to-nurse call, creating a new patient admission in the electronic medical record and entering all treatment orders and medications.
- Complete initial, concurrent, and retrospective reviews of patient care in a timely manner to ensure continuous coverage for patients in inpatient treatment.
- Initiate, schedule, and meaningfully participate in peer reviews and expedited appeals between third-party payers and facilities as needed.
- Maintain sophisticated and current knowledge of mental health disorders including DSM-V knowledge, ICD-10 diagnoses and treatment processes.
- Utilize clinical information and knowledge of medical necessity criteria to effectively communicate plans of care to insurance case managers, facility staff, and healthcare partners including the admitting psychiatrist.
- Collaborate with the treatment team to discuss clinical authorization and quality of care.
- Consistent and timely response to emails and other communications relating to utilization review.
- Prepare and submit appeals utilizing their independent knowledge and expertise.
- Familiarity with processing correspondence with adherence to HIPAA guidelines.
- Complete all data tracking as needed.
- Perform all duties of the Psychiatric Nurse (RN) role as needed or when assigned by management.
OTHER DUTIES:
- Attend scheduled staff meetings, supervision, and on-going training.
- All required training, certifications and licensure must be kept current in accordance with applicable licensing and accreditation regulations and standards.
- Respect the privacy of patients and hold in confidence all information obtained during the patient’s treatment. All patient-related documents should be handled in accordance with Agency guidelines on confidential material.
- Maintain high standards of ethical and professional conduct and adhere to Agency policies and procedures.
- Ability to perform job responsibilities with a high degree of initiative and independent judgement.
- Ability to deal with crisis situations which require prompt decision making and action.
- Demonstrated oral and written communication skills and effective interpersonal skills.
- Other duties as assigned by management.
QUALIFICATIONS:
- Education: Associate’s Degree in Nursing required. Bachelor’s or Master’s degree in related field preferred.
- Licensure: Valid Ohio RN license required.
- Skills: Sensitivity in relating to persons of varying backgrounds and demonstrated ability to work with diverse groups of people possessing various strengths, aptitudes and abilities.
Ability to perform job responsibilities with a high degree of initiative and independent judgment.
Demonstrated oral and written communication skills and effective interpersonal skills.
Proficiency in using Agency computer systems and software as required to perform essential job functions. Practical and creative problem-solving skills. - Experience: A minimum of 1-2 years’ related experience required. 3-5 years related experience preferred.
At Bluestone, we prioritize our employees and their wellbeing. We provide competitive benefit options to our employees and their families, including domestic partners.
Our offerings include:
- Comprehensive health and Rx plans, including a flat rate ($5, $10, $15) option.
- Wellness program including free preventative care
- Generous paid time off and holidays
- 50% tuition reduction at Case Western Reserve University for the MNO and MSW programs
- 403(b) retirement plan with an employer match
- Pet insurance
- Employer paid life insurance and long-term disability
- Employee Assistance Program
- Support for continuing education and credential renewal
- Ancillary benefits including: dental, vision, voluntary life, short term disability, hospital indemnity, accident, critical illness
- Flexible Spending Account for Health and Dependent Care
JOB SUMMARY: The Utilization Review (UR) Registered Nurse independently facilitates clinical reviews, as necessary, on admission and for continued stay care. The UR Registered Nurse reviews the medical record to ensure medical necessity of admission as well as ongoing inpatient and outpatient treatment. The UR Registered Nurse also determines the avenues for advocacy on behalf of patients with insurance for utilization of insurance benefits throughout the patient’s treatment. Further, the UR Registered Nurse responds to intake inquiries via phone, fax and email. Additionally, UR Registered Nurse functions as an overnight psychiatric nurse on a routine basis.
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