What are the responsibilities and job description for the Quality/Utilization Review Nurse position at George C. Grape Community Hospital?
Quality/Utilization Review Nurse
Position Summary:
The Quality/Utilization Review Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. This role ensures compliance with regulatory standards, hospital policies, and payer requirements while promoting optimal patient outcomes and cost-effective care. Additionally, this position oversees the Infection Control Nurse to ensure adherence to infection prevention protocols and regulatory compliance.
Key Responsibilities:
o Conduct concurrent and retrospective reviews of patient charts to assess medical necessity and level of care.
o Collaborate with physicians and clinical teams to ensure adherence to evidence-based guidelines.
o Communicate with insurance providers for pre-certifications, continued stay reviews, and authorizations.
o Monitor compliance with hospital quality standards and accreditation requirements (e.g., Joint Commission, CMS).
o Identify trends in care delivery and participate in performance improvement initiatives.
o Assist in root cause analysis for adverse events and recommend corrective actions.
o Supervise and support the Infection Control Nurse in implementing infection prevention and control programs.
o Ensure compliance with CDC, OSHA, and state regulations regarding infection control practices.
o Review infection surveillance data and collaborate on corrective action plans.
o Maintain accurate and timely documentation of reviews and findings in the electronic health record (EHR).
o Prepare reports for leadership on utilization patterns, denials, quality metrics, and infection control outcomes.
o Educate clinical staff on documentation requirements, utilization management processes, and infection control standards.
o Serve as a liaison between clinical teams, case management, infection control, and payers to resolve care coordination issues.
Qualifications:
o Minimum 2–3 years of clinical nursing experience (acute care preferred).
o Prior experience in utilization review, case management, quality improvement, and infection control strongly desired.
o Strong knowledge of medical necessity criteria (e.g., InterQual, Milliman) and infection control standards.
o Excellent communication, critical thinking, and leadership skills.
o Proficiency in EHR systems and Microsoft Office Suite.
Work Environment:
Shift : Day
Contact Information
Kristen Easley - Human Resources Director
2959 US 275
HAMBURG, IA 51640
Email: keasley@grapehospital.com
Phone: 712-382-1515 Ext 8701
The Quality/Utilization Review Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. This role ensures compliance with regulatory standards, hospital policies, and payer requirements while promoting optimal patient outcomes and cost-effective care. Additionally, this position oversees the Infection Control Nurse to ensure adherence to infection prevention protocols and regulatory compliance.
Key Responsibilities:
- Utilization Review:
o Conduct concurrent and retrospective reviews of patient charts to assess medical necessity and level of care.
o Collaborate with physicians and clinical teams to ensure adherence to evidence-based guidelines.
o Communicate with insurance providers for pre-certifications, continued stay reviews, and authorizations.
- Quality Assurance:
o Monitor compliance with hospital quality standards and accreditation requirements (e.g., Joint Commission, CMS).
o Identify trends in care delivery and participate in performance improvement initiatives.
o Assist in root cause analysis for adverse events and recommend corrective actions.
- Infection Control Oversight:
o Supervise and support the Infection Control Nurse in implementing infection prevention and control programs.
o Ensure compliance with CDC, OSHA, and state regulations regarding infection control practices.
o Review infection surveillance data and collaborate on corrective action plans.
- Documentation & Reporting:
o Maintain accurate and timely documentation of reviews and findings in the electronic health record (EHR).
o Prepare reports for leadership on utilization patterns, denials, quality metrics, and infection control outcomes.
- Education & Collaboration:
o Educate clinical staff on documentation requirements, utilization management processes, and infection control standards.
o Serve as a liaison between clinical teams, case management, infection control, and payers to resolve care coordination issues.
Qualifications:
- Education: Registered Nurse (RN) license required; BSN preferred.
- Experience:
o Minimum 2–3 years of clinical nursing experience (acute care preferred).
o Prior experience in utilization review, case management, quality improvement, and infection control strongly desired.
- Skills:
o Strong knowledge of medical necessity criteria (e.g., InterQual, Milliman) and infection control standards.
o Excellent communication, critical thinking, and leadership skills.
o Proficiency in EHR systems and Microsoft Office Suite.
Work Environment:
- Hospital setting with frequent interaction with physicians, nurses, and administrative staff.
Shift : Day
Contact Information
Kristen Easley - Human Resources Director
2959 US 275
HAMBURG, IA 51640
Email: keasley@grapehospital.com
Phone: 712-382-1515 Ext 8701