Utilization Nurse Case Review

Performs specialized administrative duties pertaining to utilization review, audit, billing and reimbursement activities, utilizing knowledge of both nursing and administrative practices. Assists in the coordination of billing audits with third party agencies, and as requested by BTNRH administrative team. Conducts concurrent reviews of billings for selected discharges and performs managed care defense audits and under/over charge audits; reviews charge-related patient grievances; reviews denied charges, recommends appeals and/or facilitates the resolution of root causes where appropriate; communicates audit and analysis findings to various parties. Assists the PFS management team with the analysis, development, generation and presentation of information critical to the measurement and ongoing trending of various aspects of the BTNRH revenue cycle. Assumes responsibility and accountability for the management of utilization review through ensuring timely review of all hospital admissions and insurance authorization. Collaborates with Medical Director for education of review process for medical staff and Boys Town physician leaders.

SCHEDULE: Mon-Fri 8a-4:30p. Rotating Rounds every 4 weeks.

MAJOR RESPONSIBILITIES & DUTIES:

Reviews the appropriateness of patient status for all admissions to BTNRH utilizing approved inpatient care criteria guidelines (InterQual, Millian)

• Performs assessment based on clinical indicators and anticipated services for appropriate level of hospital care considering safety, quality, and cost.

• Works with the patient/family to assess needs related to diagnosis, care, and discharge plans to establish preliminary expectations of care delivery with the family, ensuring they are actively involved or represented in the plan of care. Provides leadership to the care team to accomplish outcomes. Coordinates with the healthcare team to identify and implement appropriate discharge plans incorporating opportunities for alternative care when appropriate.

• Communicates and collaborates with third party payers as necessary to provide information relating to the plan of care, regulatory requirements, and benefits management.

• Contacts physician and other healthcare professionals when admission does not meet acute care guidelines, if additional documentation is necessary to support level of care, or when admission and or continued stay denial occurs.

• Guides admitting physician in protocols for conducting peer to peer review with third party payers.

• Monitors all Observation patients and performs conversions to Inpatient or Outpatient status as appropriate.

• Establishes and maintains a log of admissions denied by carriers.

• Documents all discharge, assessments of appropriateness of Inpatient or Observation status, and all other UR activities performed on a concurrent basis in Next Gen Financials, trending data and issues. Communicates findings to immediate supervisor and/or others as requested.

• Notifies appropriate members of the BTNRH interdisciplinary team of all status changes and participates in meetings as needed or requested.

• Provides retro reviews as needed to secure coverage on all inpatient days.

• Conducts concurrent clinical reviews against standard InterQual criteria for the purpose of evaluating medical necessity on a daily basis regardless of payer type.

• Assesses and intervenes when necessary to assure the appropriateness of patient status in regard to Observation, Inpatient, and Outpatient services.

• Provides relevant clinical information to insurance companies as required to obtain certification numbers and approved days with documentation on worksheet to comply with necessary requirements for appropriate reimbursement.

• Assists with the coordination of the appeal process for denied services, including writing appeal letters.

• Maintains a membership with the Professional Utilization Review Organization.

• Educates clinical staff and other interested parties on Interqual and/or Milliman criteria.

• Develops implements and maintains utilization review policies and procedures.

• Educates families regarding insurance benefits and adding newborns to their insurance.

• Conducts concurrent reviews of all selected discharges by reconciling charge source systems to clinical documentation and makes appropriate charges and adjustments to patient account in the billing system based on the results.

• Performs routine and impromptu charge audits as directed by the Administrative team, leadership or through the patient concern/dispute process, to ensure billed charges are supported within the clinical documentation, as well as to identify missing or over-stated charges on the account &/or claim form and communicating results back to the appropriate party(s).

• Ensures that all requests for account audits by third party agencies are scheduled and investigated in a timely and accurate manner. Reviews account audit findings with representatives of 3rd party agencies, substantiating the BTNRH charge and/or documentation. Also develops appropriate suggested action plans and communicates overall findings to the Director of PFS.

• Responsible for monitoring statistical data based on audit results and concurrent reviews. Effectively works with ancillary departments to correct charge inequities and/or identify charge systems that are functioning at less than optimum levels.

• Designs and documents clinical workflows (new and existing) to ensure understanding of all items included (i.e., system, resource, supply, cost, time, etc.) in providing the service and communicating findings to appropriate party(s), as needed, with recommendations when necessary to improve documentation and charging efficiency, effectiveness &/or compliance.

• Recommends and implements quality control systems to ensure that clinical and charging workflows are efficient, effective, and in compliance with internal and external laws, policies, and standards. Ensures that operations comply with requirements for patient confidentiality and information security.

• Assists the Director of PFS with the development and maintenance of documents such as administrative policy and procedure and external auditing requirements as directed by agencies such as The Joint Commission and other regulatory agencies by conducting special studies and projects as assigned; researches and analyzes information: prepares statistical and narrative reports and documents as needed to ensure an appropriate audit trail is maintained at all times.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Knowledge of The Joint Commission standards and other regulatory/accreditory agencies.

• Strong organizational skills with ability to proactively prioritize needs and effectively manage resources.

• Knowledge of Utilization Review and Concurrent planning through use of Interqual and/or Milliman criteria and payer resources, preferred.

• Possesses analytical and problem-solving skills necessary to perform accurate and extensive audits on selected patient accounts and revenue cycle analysis.

• Ability to serve as a positive role model, supporting the mission of the organization.

• Ability to independently manage multiple priorities.

• Maintains a high level of integrity, confidentiality and professionalism.

• Ability to communicate clearly and concisely both orally and in writing, with all staff, providers, and patients in all aspects of the job to allow efficiency and promptness for patient care.

• Ability to work in a fast-paced environment with frequent interruptions.

• Ability to respond quickly and calmly to emergencies and stressful situations.

• Ability to utilize a variety of computer programs to manage work; familiarity with Windows and Office programs such as Word and Excel.

• Good communication, assessment, and organizational skills.

• Good PC skills, including experience with Microsoft Outlook, Word, and Excel.

• Good public relation skills

• Detail oriented.

• Knowledge of compliance issues and their importance and consequence.

REQUIRED QUALIFICATIONS:

• A registered nurse who is a graduate of an accredited school with a current state license required.

• Knowledge of pediatric/adult nursing clinical practice, compliance and/or medical auditing, coding, utilization review, and/or other related healthcare experience required.

• Minimum of five years of experience involving decision-making with knowledge of utilization review activities required.

• CPR certification required.

• Experience with billing and EMR software applications as they apply to the computerized patient record required.

PREFERRED QUALIFICATIONS:

• Bachelor's degree in Nursing preferred.

• Ability to apply InterQual and/or Milliman criteria preferred.

• Background in Medicare, Medicaid, third-party billing, compliance and reimbursement regulations preferred.

About Boys Town:

Boys Town has been changing the way America cares for children and families since 1917. With over a century of service, our employees have helped us grow from a small boardinghouse in downtown Omaha, Nebraska, into one of the largest national child and family care organizations in the country. With the addition of Boys Town National Research Hospital in 1977, our services branched out into the health care and research fields, offering even more career opportunities to those looking to make a real difference.

Our employees are our #1 supporters when it comes to achieving Boys Town's mission, which is why we are proud of their commitment to making the world a better place for children, families, patients, and communities. Unique perks to Boys Town employees and their families include free visits to Boys Town physicians and free prescriptions under the Boys Town Medical Plan, tuition assistance, parenting resources from our experts and professional development opportunities within the organization, just to name a few. Working at Boys Town is more than just a job, it is a way of life.

This advertisement describes the general nature of work to be performed and does not include an exhaustive list of all duties, skills, or abilities required. Boys Town is an equal employment opportunity employer and participates in the E-Verify program. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and/or expression, national origin, age, disability, or veteran status. To request a disability-related accommodation in the application process, contact us at 1-877-639-6003.