Registered Nurse Utilization Review PRN-Case Management-PRN

CHRISTUS Health - Alexandria, LA

Full-time - Mid Level

Alexandria, LA

Ambulatory Health Care Services

About the position

The RN Utilization Review II is responsible for assessing the clinical appropriateness of patient care and ensuring effective utilization of hospital resources. This role involves conducting various reviews related to pre-admission, concurrent, and retrospective utilization management (UM). The RN must utilize approved screening criteria and maintain knowledge of regulations and guidelines from commercial and government payors, as well as the Joint Commission. Effective communication with clinical professionals and insurance providers is essential to obtain necessary service certifications.

Responsibilities

• Determine the clinical appropriateness of care provided to patients.
• Perform pre-admission, concurrent, and retrospective utilization management reviews.
• Utilize approved screening criteria such as InterQual and MCG.
• Manage a diverse workload in a fast-paced regulatory environment.
• Maintain knowledge of commercial and government payors and Joint Commission regulations.
• Communicate effectively with internal and external clinical professionals.
• Organize financial insurance care for patients and relay clinical data to insurance providers.

Requirements

• BSN Degree from an accredited nursing program or proven success as Registered Nurse Utilization Review I role.
• Three to five years of experience in case management or utilization review.
• RN License in state of employment or compact required.
• Excellent verbal and written communication skills.
• Critical and analytical thinking skills.
• Demonstrated clinical competency.

Nice-to-haves

• Familiarity with criteria sets including InterQual and MCG preferred.
• CPR certification preferred.
• Certification in Case Management preferred.