The UR Specialist is responsible for utilization review of all inpatient charts, discharge planning for Medically Complex patients (or those meeting RN Care Coordinator criteria). Functions as community liaison, making referrals as appropriate. Communicates with insurers and physicians to ensure compliance with contracted guidelines, and to promote optimal patient care through the continuum of care. Works closely with Social Work Care Coordinators, all clinical staff, patients and families.
- Participates in patient care planning committee.
- Concurrently reviews medical charts for clinical pertinence and intervenes as necessary to facilitate compliance.
- Assists in data collection for UM reporting and QA.
- Follows the chain of command when critical non-compliance issues arise. (See Medical Staff Bylaws) Keeps current on Medicare/Medicaid guidelines and insurance contracts.
- Other duties as assigned.
- This position requires strict adherence to the CMSA Standards of Practice for Case Management.
- RN, BSN preferred.
- Case management/UR certification preferred.
- 5 years clinical nursing, 1 year case management or home care preferred.
- Must have excellent communication skills.
- Ability to collaborate and cooperate with other disciplines.
- Excellent negotiation and conflict management skills.
- Must have a good understanding of non-nursing disciplines and community resources.
- He/she must consistently use good judgment in dealing with all internal and external customers.
- Maintains professional demeanor at all times when representing Platte Valley Medical Center.
- Is knowledgeable about Medical Ethics.
- Knowledge of Medicare, Medicaid, InterQual and Millman and Roberts’ UR guidelines preferred
Organization: Platte Valley Medical Center, Brighton, CO
Primary Location: CO-Brighton
Department: PVMC-Social Work Services
Shift: Day Shift
Job Number: 18001307