GLOSSARY

Utilization review/management nurse -  These professionals spend most of their time reviewing medical records and writing recommendations based on established guidelines and nursing judgement.

Medical-Surgical Nursing- "Medical-surgical nursing is the single largest nursing specialty in the United States and beyond. Medical-surgical nurses provide care to adults with a variety of medical issues or who are preparing for/recovering from surgery. They have a broad knowledge base and are experts in their practice. Medical-surgical nurses have advanced organizational, prioritization, assessment and communication skills and are leaders in coordinating care among the interprofessional health care team.   Medical-surgical nursing is practiced in several settings across the health care industry, including hospitals, outpatient settings, in homes, via telemedicine and other non-traditional settings. The specialty of medical-surgical nursing happens in almost every care environment because medical-surgical nursing is what you practice, not where." Source: Academy of Medical Surgical Nurses

Step Down ICU -  "Step Down Units (SDUs) provide an intermediate level of care between the Intensive Care Units (ICUs) and the general medical-surgical wards. These units, which are also commonly referred to as intermediate care units and transitional care units, are found in many, but not all, hospitals in developed nations.  The purpose of an SDU is to treat patients who are more severe than the typical ward patient, but who do not require as intense monitoring as the most critical ICU patients" Source: Columbia University  cc.pdf (columbia.edu) 

Bariatric Nurse- A registered nurse who  cares for morbidly obese and bariatric surgery patients.

Appeals Nurse -  Serving as the defense for a patient with a rejected claim, a clinical appeals nurse must provide sufficient medical evidence to support any appeal.   A clinical appeals nurse handles all aspects of an appeal. They assess the patient’s situation, including every detail related to the insurance claim, its denial, and the treatment to be received . Source: What is a Clinical Appeals Nurse? (wgu.edu)  

Denials Nurse- The primary responsibility of the Denials Management Nurse is to utilize clinical expertise, insurance knowledge, business know-how, and high level communication to analyze the patient’s accounts, medical records and invoices to assist in the resolution for retrospective approval for denied services and possibly continued access needs. Source:  Denials Management Nurse | ursolutions 

Care Guidelines Specialist in Utilization Mangement Certification -  Recognizes staff achievement by conferring expert status on those who have demonstrated competence in the use of the care guidelines. MCG uses transparent assessment of the latest research and scholarly articles and data analysis to provide unbiased clinical guidance. Source:  Evidence-Based Care Guidance and Solutions | MCG Health 

Clinical Documentation Integrity (CDI)-  CDI is a term that refers to the quality and accuracy of the health records of patients. CDI involves the best practices, processes, technology, and people that ensure the completeness, precision, and validity of the clinical documentation. CDI also supports the use of the health records for reimbursement claims, patient identification, data analysis, and future care. 

Source:  Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update) (ahima.org) ;  The Art of Clinical Documentation Integrity (CDI) | AHIMA International ;  What Is Clinical Documentation Integrity and Why Is It So Important - American Celiac