RN - Utilization Review

Shift Details

Shift 8 hour days

Job Order Details

Start Date 2025-10-21

End Date 2025-12-15

Duration 8 Week(s)

Client Details

City Fredericksburg State VA

The Registered Nurse (RN) – Utilization Review (UR) is responsible for ensuring that healthcare services provided to patients are medically necessary, appropriate, and efficient. The RN in this role works with healthcare providers, insurance companies, and patients to review medical records, treatment plans, and clinical data to determine the appropriate level of care and ensure compliance with healthcare policies and regulations. This role requires a strong understanding of clinical care, health insurance guidelines, and hospital operations to make informed decisions that optimize patient care and resource utilization.

Key Responsibilities:

1. Utilization Review and Clinical Evaluation:

   • Review patient medical records, treatment plans, and clinical data to assess the appropriateness of the care being provided and the necessity for continued hospitalization or services.
   • Assess the medical necessity of procedures, tests, and treatments to ensure they align with established guidelines and criteria, such as those from the InterQual or Milliman Care Guidelines.
   • Evaluate whether the care provided is appropriate, efficient, and meets the standards of care based on clinical evidence.

2. Collaboration with Healthcare Providers:

   • Collaborate with physicians, case managers, and other healthcare professionals to ensure that patient care plans are appropriate and cost-effective.
   • Communicate with healthcare teams to discuss any discrepancies or concerns regarding the utilization of resources, care plans, or treatment goals.
   • Provide recommendations or alternative care options to improve patient outcomes and optimize resource utilization.

3. Insurance and Payer Interaction:

   • Work closely with insurance companies, managed care organizations, and government payers (e.g., Medicare, Medicaid) to review cases for coverage, authorization, and reimbursement.
   • Submit necessary documentation and justification to insurance companies to support medical necessity determinations and secure prior authorization for treatments, procedures, or extended hospital stays.
   • Resolve any issues related to denied claims or requests for additional documentation to ensure that services are covered by insurance providers.

4. Monitoring of Length of Stay and Discharge Planning:

   • Monitor patient length of stay (LOS) to identify potential delays in discharge and ensure that patients are not staying in the hospital longer than necessary.
   • Work with case management teams to develop appropriate discharge plans, ensuring that the patient is ready for discharge and has the necessary resources and follow-up care.
   • Identify potential barriers to discharge and collaborate with the interdisciplinary team to address these issues and facilitate a timely discharge.

5. Compliance and Quality Assurance:

   • Ensure that utilization review practices comply with regulatory standards, including The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and other state or federal regulations.
   • Assist with audits to evaluate the efficiency and accuracy of utilization management processes, making improvements where necessary.
   • Maintain up-to-date knowledge of healthcare regulations, coding guidelines (ICD-10, CPT), and payer-specific policies to ensure accurate documentation and compliance.

6. Documentation and Reporting:

   • Document findings from utilization reviews in the appropriate systems and ensure accurate record-keeping for insurance purposes and quality improvement efforts.
   • Prepare reports on utilization metrics, including patterns in hospital admissions, readmissions, and discharge delays, for management and leadership review.
   • Provide detailed, evidence-based rationales for medical necessity determinations and collaborate with the healthcare team to ensure compliance with UR protocols.

7. Case Review and Decision-Making:

   • Perform retrospective and concurrent review of patient cases to determine if the level of care aligns with guidelines and if resources are being utilized efficiently.
   • Recommend the appropriate level of care (e.g., inpatient, outpatient, skilled nursing facility) based on clinical findings and guidelines.
   • Provide feedback to clinicians and healthcare teams regarding any areas for improvement in care planning or resource utilization.

8. Education and Training:

   • Educate staff and providers on the importance of utilization review processes, medical necessity criteria, and compliance with payer requirements.
   • Stay current on the latest healthcare policies, clinical guidelines, and best practices for utilization management.
   • Participate in continuing education and training programs related to UR, case management, or quality improvement initiatives.