The Utilization Review RN PRN is responsible for utilization management and utilization review for prospective, concurrent, or retrospective review. This job functions as a part of a multidisciplinary team, including physicians, social workers, discharge planning assistants and payers, performs reviews of current inpatient services, and determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. The Utilization Review RN PRN conducts prospective, concurrent and retrospective utilization review for inpatient services, observations, as well as specific outpatient service requests. Licensure, Certification, or Registration Requirements for Hire: Licensed Registered Nurse in the State of Virginia or eligible Licensure, Certification, or Registration Requirements for continued employment: Current RN licensure in Virginia Complete 15 Continuing Education Units per year Experience REQUIRED: Minimum of three (3) years of nursing experience in an acute care setting Experience PREFERRED One (1) year of Care Coordination experience Clinical experience with specialty patient population Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc.). Proficient in Milliman Care Guidelines (MCG) or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management. Education/training REQUIRED: Bachelors of Science in Nursing from an accredited School of Nursing Education/training PREFERRED: Master’s Degree in Nursing or a healthcare related field from an accredited program Case Management Certification Independent action(s) required: Works with the attending and consulting physicians to facilitate effective and efficient transition through the process of hospitalization. Works collaboratively with all members of the multi-disciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum, as well as appropriately reimbursed by payers as contracted, and that resources are efficiently and effectively utilized. Utilizes medical necessity criteria as a tool to assess appropriateness of level and setting of care, assists in the denial and appeals process, assesses quality, and identifies and reports potential risk management issues. Responsible for participation in and completion of all patient safety initiatives appropriate to the position. Establishes and maintains a professional rapport with providers, patients/families, and internal customers. Trains and educates new UM staff nurses and new RN Care Coordinators by demonstrating job competency, providing technical instruction and leadership and generally raising the level of performance of others (within and outside of the department) Advocates that the patient is placed in the status and level of care for appropriate remuneration of services rendered. Utilizes clinical application systems with fundamental proficiency in utilization review systems and uses business support applications as needed Supervisory responsibilities (if applicable): N/A Additional position requirements: Ability to flex the schedule as needed to meet the demands of the department Age Specific groups served: All Physical Requirements (includes use of assistance devices as appropriate): Physical Lifting 20-50 lbs. Activities: Prolonged sitting, Repetitive motion Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking Emotional: Fast pace environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Able to adapt to frequent change EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4. Who We Are Inventing better care, day by day by discovery Sound outrageous? It absolutely is. Sound impossible? That’s never stopped us before. Sound like hard work, intense research, collaboration with experts around the world, sheer brainpower meets unrelenting willpower? That’s. Exactly. Right. We’ll do whatever it takes to offer the best in care and empower the best in quality of life. And it’s an approach that works — whether it’s a patient who undergoes a new, life-saving procedure or a clinical researcher who finds promise in a new cancer treatment, exciting new medicine is happening at VCU Health. We have it all: • One college and four health sciences schools • An academic medical center • A Level I trauma center • One of only two NCI-designated cancer centers in Virginia • The region’s only full-service children’s hospital • More than 800 physicians in 200 specialties • With a community health center, dedicated research teams, facilities and valued partners in every field Our medical teams are top notch. And we’re not too shy to boast of internationally known physicians, some recognized as the best in the country, top-ranked local specialists and all-around all-stars at every level. From our very first years to our most recent advancements, we are driven to learn more, dig deeper, teach passionately and never rest in order to be a true leader in discovering what’s possible in health and recovery. We are a comprehensive system of care and a pioneer of health. Read VCU Health Year In Review for more about our accomplishments.