RN Utilization Review

Overview

Job Summary The Utilization Review Nurse is responsible for evaluating the medical necessity and appropriateness of healthcare services and treatment as prescribed by utilization review standards. The UR Nurse works with providers, insurance companies and patients to ensure cost-effective and appropriate care. Areas of work include status management, medical necessity reviews, verification of authorization, resource utilization, and denial prevention.

Job Responsibilities

• Completes and enters inpatient and observation admission review against standard criteria per payer guidelines
• Prioritizes observation case review
• Assists with level of care in collaboration with attending provider
• Enters working diagnosis-related groups (DRGs) in the electronic medical record
• Submits clinical information to payer per payer requirements
• Completes continued stay reviews every 3 days or more often if required
• Communicates with care coordinators for authorized days, level of care, medical necessity or other areas when indicated
• Communicates with physician advisors related to status concerns or denials
• Updates auth/cert screen in the electronic medical record
• Works assigned queues in the electronic medical record
• Communicates with authorization coordinator
• Communicates in-house high dollar case information
• Completes assigned goals
  
  

Description Minimum Required Preferred/Desired RN with 3 years of clinical experience RN with Case Management or Utilization Review experience in a hospital or payer setting Education Description Minimum Required Preferred/Desired Diploma or Associate Degree in Nursing BSN or MSN Training Description Minimum Required Preferred/Desired Special Skills Description Minimum Required Preferred/Desired Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills. Problem solving; and knowledge of governmental regulations. Licensure Description Minimum Required Preferred/Desired RN RN;CCM;ACM