Please provide specific details regarding job duties, language requirements, skills, days and hours of work, and

any other special requirements or information in the space below. You may also attach a job description.

Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care.

Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on

appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation

services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight

stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to

conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical

reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations,

policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and

appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce

length of stay and resource consumption.

Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital

entry

Job Summary (continued):

Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR

preferred.

Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience.

Other Credentials: Registered Nurse - NJ

Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning

experience. CPHQ, CCM or CPUR preferred.

Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses

familiarity with MCG guidelines.

Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in

situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram,

or schedule form.

Usual Work Day: 8 Hours

Capital Health

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