RN - Inpatient Utilization Review
Posted on: June 24, 2022
Responsible for the oversight, coordination, and management of
the functional and financial outcomes during acute illness
requiring hospitalization for patients of the Carle Foundation
Hospital. Facilitates the care of patient by insuring that
admissions and continued days are medically necessary,
cost-effective, and provided in the appropriate level of care to
qualify for reimbursement.
- The UM staff RN will function within the IP Care Coordination
Department to ensure that the most cost-effective and appropriate
use of health care services for patients treated by Carle
- Ensures efficient patient flow and throughput
- Initial assessment of all new patients for correct status
(admission/observation/outpatient) based on UR medical necessity
- Performs concurrent reviews of all patient charts to ensure
proper resource utilization as necessary to identify practice
- Keeping LOS within patients working DRG.
- Send clinical documentation to insurance companies per their
- Communicate with physicians on status changes and
- Refers cases for secondary review when appropriate.
- Refers cases for escalated medical review when services do not
meet medical necessity criteria and/or appropriate level of
- Documents utilization reviews/issues in appropriate locations,
including but not limited to case management/utilization review
- Track Avoidable days.
- Educates and assists physicians in resource utilization.
- Participate in extended care reviews and attend meetings.
- Review cases for potential quality indicators and refers to UM
- Works with Appeal staff to actively appeal cases concurrently
- Strong attention to detail is required, as to minimize any
misunderstandings regarding services authorization of or denial of
- Possess a working knowledge of Carle's organization and IPCC
operations and administrative standards and policies.
- Expert with acute level of care criteria. Apply severity of
illness and intensity of service to determine appropriateness of
- Excellent interpersonal communication and the ability to
interact with healthcare professionals in all disciplines. The
ability to effectively communicate with physicians, payers, and
hospital staff in a non-confrontational manner and provide
excellent customer service.
- Ability to build rapport with medical staff, hospitalists
services, and hospital leadership to obtain collaboration necessary
to achieve desired UM outcomes.
- Strong data management and computer skills (Word, Excel.
Outlook, and EPIC Case Management software.
Keywords: CARLE, Champaign , RN - Inpatient Utilization Review, Healthcare , Oakland, Illinois
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