Registered Nurse Utilization Review

About the position

The Registered Nurse Utilization Review position is responsible for coordinating care plans for assigned members, conducting pre-certification, concurrent reviews, discharge planning, and case management. The role focuses on efficient utilization of health services to achieve optimal health outcomes for members while meeting designated quality metrics.

Responsibilities

• Perform risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service utilizations based on clinical documentation, regulatory, and InterQual.
• Ensure care is delivered in a fiscally responsible manner.
• Report exceptions and variances to the Quality Committee and/or responsible staff.
• Make informed recommendations regarding Level of Care, Length of Stay, and appropriateness of documentation for medical necessity.
• Ensure payer requirements are met to ensure payment for services rendered.
• Assist in denial appeals as needed.
• Monitor insurance for payment/care trends and patterns and refer to appropriate staff.
• Compile and integrate information as needed.
• Act as a liaison with providers, patients, families, payers, CMS, and QIO.
• Function as a clinical resource for the multi-disciplinary care team to maximize quality of care while achieving effective medical cost management.
• Maintain current knowledge of Utilization strategies.
• Review continued stays using nationally approved criteria.
• Ensure payer requirements are met for reimbursement.
• Consider, address, and coordinate needs outside of the facility as needed.
• Comply with payer requirements to maximize reimbursement for post-discharge services and minimize costs to patients.
• Comply with federal and state regulations concerning financial interest disclosure and choice of provider.
• Compile statistics and monitor for trends.
• Attend and report at Quality and MEC meetings for any Utilization Management needs.
• Write, review, and update departmental Policies and Procedures.
• Represent UR at departmental meetings, including Quality Meeting, Medical Staff, and MEC meetings as needed.
• Assist with third-party appeals and communications.
• Work closely with the Business Office, Revenue Cycle Analyst, and HIM to facilitate the reimbursement process.
• Collaborate with Quality Management/Case Managers to ensure quality care is extended to each patient and family.
• Maintain current knowledge of relevant case management and utilization management policies, laws, and practices.
• Perform other duties as assigned.

Requirements

• Associate or Bachelor's Degree in Nursing.
• Current state RN licensure.
• 5 years of Utilization Review experience preferred.
• Experience in a fast-paced environment; orthopedic and spine experience strongly recommended.

Nice-to-haves

• Experience in Care plans.

Benefits

• 401(k)
• Health insurance
• Paid time off
• Dental insurance
• Disability insurance
• Life insurance
• Paid holidays