Position Summary Conducts reviews of the patient’s medical data to assess appropriateness and medical necessity for admission and continued stay, to assist in assigning an appropriate DRG/LOS that reflects care required by the patient, and to facilitate continuing care planning based on patient’s needs. Assists in identifying underutilization and overutilization of health care resources. Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation. Obtains appropriate clinical documentation and ensures that the clinical information used in measuring and reporting medical necessity and outcomes is complete and accurate. Educates members of the patient care team on medical necessity documentation guidelines. Works collaboratively with the Patient Care Team through regular communication and information sharing. Collects data for analysis and report generation. Minimum Qualifications Work Experience Three years of recent clinical Registered Nurse experience in a hospital setting required. Case Management, Utilization Review and/or Coding experience preferred.
Education Graduate of a school of nursing required.  Bachelor’s degree in nursing or related field preferred.
Certifications/Licensure Kentucky RN license (OR) RN license in a State recognized by the Kentucky Nurse Licensure Compact Act required effective June 1, 2007.  Job Specific Performance Standards The duties listed below are a summary of the major essential functions of this position. The position may require other duties, both major and minor, that are not mentioned, and specific functions may change from time to time.
  Determines appropriateness of admission, continued stay, and readiness for discharge based on medical necessity following established guidelines of provider and hospital policies. Initiates interdisciplinary referrals when appropriate and ensures interdisciplinary referrals have occurred. Performs admission and continued stay reviews. As appropriate, participates in Performance Improvement data collection, evaluation and recommendations for improvement. Refers quality issues to the Department Director. Educates internal customers on medical necessity documentation opportunities and reimbursement issues, as well as performance improvement methodologies. Interacts effectively with the physician regarding documentation appropriate to diagnosis and severity of illness. Communicates effectively with colleagues to clarify issues and collaboratively obtain complete and accurate documentation in the medical record, and participates in Team Meetings. Refers cases where medical necessity and/or appropriateness of care is unclear to the attending physician, and/or department director. Refers cases to Physician Advisor (PA), when appropriate as outlined in the PA referral policy and procedures. Effectively communicates pertinent clinical data to appropriate providers for admission and continued stay certification in collaboration with Department Coordinators, and informs hospital departments/personnel, physician and patient, as indicated, of authorization and/or denials.  Reports to department director possible inefficient utilization of resources. Reports denials as indicated to appropriate agencies, hospital departments and physicians. Evaluates denials for appropriateness of appeal, coordinates the appeal process with the Audit & Appeals department and Department Coordinators. Accurately enters required information in the medical record and computer system.