This position exercises independent judgment in ensuring that each hospital patient receives a timely concurrent review with intervention as established by the Utilization Review Plan and Social Service Discharge Plan. The Hospital Utilization Nurse will be responsible for concurrent review of all patients upon admission to Waldo County General Hospital and daily thereafter for continued medical necessity and plan of care.Provides comprehensive case management designed approach to assure appropriate allocation of the hospital’s resources and promote quality patient care in the most cost effective manner. As a Utilization Review nurse the ability to coordinate comprehensive health care needs and assessments for discharge planning needs in conjunction with Social Services Discharge Planning Department.
Required Minimum Knowledge, Skills, and Abilities (KSAs)
Education: A graduate from an accredited School/College of Nursing.
License/Certifications: Maintain active RN license in the State of Maine.
Ability to maintain confidentiality.
Ability to effectively communicate health care information to providers, hospital staff, reviewing Physician Advisor and insurance carriers.
Must be a team player with a positive attitude with self-motivation
Strong interpersonal skills and the ability to work effectively with all hospital staff throughout the hospital.
Knowledge of nursing and case management theory and practice.
Knowledge of current Medicare and MaineCare laws and requirements.
Knowledge of patient rights, denials of admission, denials for continued stay and Code Condition 44’s.
Strong conflict resolution and problem solving skills.
Knowledge of using an Electronic Health Record, utilizing accurate and timely documentation.
Knowledge of Utilization Review process and Discharge Planning, as to determine need for admission, discharge and continued stay medical necessity.
Ability to develop upon admission the implementation of utilization plan.
Attend daily PEP rounds to discuss and review discharge goals and plan of care.