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Field Utilization Review Nurse Job Details

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Company:  Nurse Resolutions
Job Code:  1549
Categories:  Skilled Nursing / Nursing Home (SNF)
Job Role:  Other
Country:  United States
Region/Province:  Kentucky (KY)
City:  Louisville
Job Description:  Responsible for medical record review and DRG validation of pre-targeted retrospective cases. The nurse performs reviews for the following targets: Medical necessity, Readmissions, Billing errors, Quality of care issues, and correct DRG assignment/principal diagnosis/principal procedure validation. InterQual acute care criteria are utilized upon admission review. Reviews are completed by the nursing staff as assigned/scheduled, no later than the last working day of the month (following that previous review month).


The RN will conduct reviews either from home base or on-site. Charts which have been sent in from the facility will be picked up at corporate office. If onsite review has been requested by the facility, the RN reviewer will travel to the respected site to conduct medical record review at that site. The facility is required to provide a well-lit work space with a power outlet for the reviewers laptop.


The RN will review the following items in the medical record: Demographics, Presentation on admission, Co morbidities/Complications, Evaluation /treatment provided, Incorrect or incomplete diagnosis, Quality of Care and Review of UB92 or UB04.

The RN will review the medical record for the following items: Validation of the information provided at the time of recertification, Readmissions, Billing errors, Quality concerns, Appropriate DRG assignment and reimbursement based on documentation.

Issues of concern, as listed above and identified by the RN reviewer, will be referred the physician for additional review.
If the RN identifies concerns while onsite, the concern will then be entered on the worksheet which is entered in the DRG database. A copy of the medical record is sent from the facility back to within 10 working days from the date of the onsite visit.

Abe Ghebrehiwet
National Account Executive
Nurse Resolutions
888.411.2228. Toll Free
407.341.9647. Cell
407.557.2270. Fax
www.nurseresolutions.com


utilization review, retrospective review, louisville
Post Date:  05/24/2012
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