The role of the Utilization Review Nurse actively supports the management of a successful compliant utilization review program through planning, process evaluation, data analysis and establishing goals to obtain entitled reimbursement and comply with regulatory and third party payer utilization guidelines. Seeks and implements methods to effectively streamline appropriate information sharing with payers and other customers. This role performs concurrent and retrospective reviews using approved criteria to evaluate severity of illness, medical necessity and appropriateness of treatment; communicates complete and accurate information to third party payers and staff; obtains authorization for payment from Medicaid and private insurance/review companies; serves as a liaison among third party payers, patient/family and staff to ensure necessary services are provided promptly and effectively; assures that complex/problematic cases are escalated for problem resolution; refers cases to the Utilization Review Coordinator and Case Management Team as appropriate; communicates and interacts with all levels of professions, including but not limited to physicians, nursing, managers, ancillary staff, and office staff using various professional, appropriate and persistent techniques in a direct yet non-confrontational manner; provides coverage for Case Management; communicates effectively to improve quality, safety, satisfaction and effective discharge planning; Knowledgeable about acute care standard concepts, practices, and procedures; Incorporates regulatory updates and guidelines into UR services; Relies on experience and judgment to plan and accomplish goals. A certain degree of creativity and latitude is required.

Duties/Responsibilities:
• Actively supports utilization review services to obtain authorization for payment from 3rd party payers in preadmission, admission and continued stay areas and outpatient certification. 
• Establishes and maintains payer contact and referral information for timely escalation of issues. 
• Assists with ongoing updates/maintenance of the UR Guide with payer specific contacts and requirements. Shares information/educates team members to ensure integrity of UR services when others provide coverage.
• Evaluates appropriateness of treatment and severity of illness using criteria approved by the Medicare Peer Review Organization. Assists with arranging peer-to-peer reviews as necessary. 
• Identifies, escalates and works to resolve system problems, barriers and delays that impede the plan of care, discharge or reimbursement; Initiates recommendations/options rather than wait for a referral.
• Communicates effectively to improve quality, safety, satisfaction and effective discharge planning. Seeks methods to effectively streamline information sharing. 
• Refers cases to Case Management Physician Advisor and takes appropriate action when cases fail criteria. 
• Collaborates and communicates with Patient Access Department and Business Office on individual cases and to ensure effective revenue cycle.
• Completes retrospective reviews from all payers through timely and effective interventions.
• Accurately and timely documents details of assessment and interventions according to established policies, procedures and methods; is detail oriented. 
• Provides evaluation, recommendations and/or referrals for performance improvement, patient safety and risk. 
• Models effective team behaviors such as constructive discussion of differences, supporting team decisions, and placing team successes above individual preferences and routines.
• Maintains competency of utilization review and Case Management guidelines and theory, pertinent State and Federal regulations and SCH policies and procedures. Provides coverage for Case Management.

Skills/Abilities: 
• The candidate must be a self-starter with the ability to foster teamwork and collaboration to achieve desired results. 
• Must exhibit excellent communication, critical thinking and analytical skills with the ability to exercise discretion and good judgment. 
• Must demonstrate ability to foster mission and CQI values. 
• Proficient in computer skills and software, benchmarking experience preferred. 
• Knowledge of nursing acute care, regulatory and accreditation requirements. 
• Self-motivated and directed with the ability to prioritize and work independently with little supervision. Strong interpersonal skills, pleasing personality and positive team player.

Education:
Graduate of a School of Nursing required; BSN preferred.

Experience: 
Minimum of five years of experience as a Registered Nurse in acute care. Case Management/Utilization Review experience preferred. 

Licensure/Certification: 
Current licensure with the Kentucky Board of Nursing as a Registered Nurse.