Utilization Review Nurse (Work From Home)
Utilization Review Nurse
**Candidate must live in or around the Orlando area**
This position will focus on initial and continued stay utilization review and denials to include assessment of medical records for appropriateness, level of care provided, including assessment of treatment modalities, medications, services and application of treatment protocols. A team approach with the facility Case Management team is critical. Provide clinical information to patient insurance plans according to the terms of the contract, receive authorization / certification for the stay, work concurrent denials, determine the correct patient status and communicate to the facilities, follow the X-Code process per HCA policy, maintain communication with the facility case managers, physicians and the Insurance Plans.
Essential Job Functions:
- Perform admission InterQual as per Plan contract or within 24 hours on all Non-Medicare Inpatients and document in Midas.
- Document note to support Inpatient admission.
- Ensure the patients status is correct (Inpatient vs Outpatient)
- Perform continued stay InterQual as per Plan contract, a minimum of every 3 days and submit to the Plan as needed.
- Review concurrent denials and work with facility, physician and Plan to overturn the denial, document in Midas Denied Days screens.
- Communicate denial status to the facility and physician.
- Follow X-Code process as per HCA policy.
- Communicate with physicians regarding patient status.
- Communicate medical necessity and responder criteria to the facility Case Manager.
- Review the Certification / Authorization report daily to determine deficiencies.
- Documentation to take place in Midas in the Care Enhance Review Manager Enterprise (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable Denied Days module.
- Autonomous and self-starter in work activities
- Ability to work independently under general instructions and with a team
- Must have accessibility to high speed DSL or Cable modem for home office and business level connectivity.