RN Utilization Review - part-time in Lander, WY at SageWest

Date Posted: 10/16/2019

Job Snapshot

Job Description

SageWest Healthcare - Riverton

The UR Assistant is responsible for collecting, analyzing and providing pertinent, timely clinical information to payer sources and external UR personnel for authorization of inpatient stay and/or outpatient services in which facilitating meeting the requirements for internal criteria for medical necessity and  appropriatness of  care.  Uses collaborative and systematic processes to assess, plan and coordinate the implementation of services that meet the individual's acute behavioral and mental health needs.  Collects and utilizes data to monitor and evaluate the appropriateness and effectiveness of those services in accordance with the organizations PHI model. Communicates with physician, payers,  case management team,  and other  providers to  achieve appropriate documentation to support the medical necessity and level of services rendered to all patients. Documents UR process within applicable  utilization review and case management programs.  Assist with the ongoing development and delivery of education on documentation guidelines, coding and reimbursement rules for all members of the patient care team. Experience analyzing patient records to determine legitimacy of admission, treatment and length of stay in the treatment facility to comply with insurance company reimbursement policies: Analyze insurance, governmental and accrediting agency standards to determine criteria concerning admissions, treatment and length of stay of patients  I Facilitates the overall quality, completeness and accuracy of the medical record. Compile and report daily to Director of Quality and Case Management to review activity and facility statistics.


•Conduct concurrent medical record review using specific indicators and criteria as approved by medical staff, TJC, CMS and other state agencies.  Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization.  •Mobilizes resources and interviews, as needed, to achieve expected desired clinical outcomes within the desired timeframe. •Ensure that patient test are appropriate utilization of services from admission through discharge.   •Reviews day to day clinical pre-certification and concurrent reviews with manage care companies, to certify various levels of care from inpatient to out patient.  •Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship.  Assist physicians to maintain appropriate cost,case,and desired patient outcomes. •Introduces self to patient and family and explains UR Assistant role and process for patient and family to contact UR Assistant. •Maintains UR documentation related to each patient's plan of care in collaboration with the case management team. •Collaborates with case management  staff in the development and execution of the plan of care, and achievement of goals. documents readmission risk assessment on patients, tracks readmission of patient within 30 days of discharge Assist Case Management team with follow up calls to discharged patients for continuum of care needs Other duties as assigned by the Director of Quality and Case Management

Job Requirements

Wyoming RN or LPN licensure or compact equivalent

Experience with patient intake or admission processing is preferred.

Minimum 3 years’ acute care experience requiredCurrent Basic Life Support (BLS) certification 


Demonstrate effective written and verbal communication skills.

Proficiency with PC word processor and spread sheet programsKnowledgeable of the principles of process improvement including data collection, analysis and reportingKnowledge or experience utilization review criteria, processes and documentation requirements Demonstrated the ability to organize and prioritizePossess knowledge of utilization management and reimbursement mechanisms(Interqual, MCG/Millman's, CMS, Medicare, Medicaid).Experience analysing patient records to determine legitamacy of admission, treatment and LOS in the treatment facility to comply with insurance company reimbursement policies: Analyze insurance, governmental ad accrediting agency standards to determine criteria concerning admissions, treatment and LOS of patients.Possess thorough understanding of Protected Health Information (PHI) associated with Health Insurance Portability and Accountability Act (HIPPA).

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran