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Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations, and documentation requirements.

Experience and Education

Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas.

RN with 6 years of clinical experience and a minimum of 3 years recent UR experience, acute care preferred.

Expert knowledge of InterQual Level of Care Criteria and knowledge of local and national coverage determination

Job Duties

Admission reviews are done concurrently at the point of entry in collaboration with ED and admitting physician and the cooperation with the access management team to determine the appropriateness of hospital level of care.

Confers with admitting physicians when documentation does not appear to support hospital level of care and offers suggestions for clarity and completeness.

Uses InterQual Level of Care Criteria for appropriateness for inpatient level of care or observation services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay.

Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians.

Proactively collaborates with admitting physician to provide coaching on accurate level of care determination at point-of-hospital entry.

Consistently identifies and records information on any progression-of-care/patient flow barriers

Actively participates in daily huddles, multidisciplinary rounds and patient care conferences to maintain knowledge about intensity of services and the progression of care.

Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes.

Knowledge, Skills, & Abilities

Identifies avoidable days (quality and risk issues), makes appropriate referrals. Confers with Manager and/or Medical Director as appropriate.

Actively participates in the department’s performance improvement initiatives.

Identifies the need for professional growth and seeks out appropriate development opportunities.

Evaluates outcomes data to identify trends and areas for improvement (i.e. avoidable days, denial information)

Working Conditions

Any qualifications to be considered as equivalents in lieu of stated minimums require prior approval of the Vice President for Human Resources Administration, or his/her designee.