Utilization Review Nurse

Job Summary

The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. There will be interaction with providers, patient, and the care team for continued UM process. Further job duties will include Denial prevention, denial management, Implementation of process improvements to mitigate payer denials & improve front-end processes, Collaboration with internal Physician Advisor and external physician advisors regarding physician practices (particularly documentation deficiencies/admission practices). This individual identifies, develops, and provides orientation, and training, for appropriate staff and colleagues on an ongoing basis. He/she actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. This individual maintains current and accurate knowledge regarding commercial and government payers and CIHQ regulations/guidelines/criteria related to UM. The UR Nurse effectively and efficiently manages a diverse workload in a dynamic regulatory environment. The UR Nurse is a member of, and provides support to, the hospital’s UR Committee. He/she collaborates with multiple leaders at various levels throughout Shannon Health, for the purpose of supporting and improving the UM program.

Qualifications

Education

• Required
  • High School Diploma, GED, or equivalent
  • Associate’s degree in Nursing
• Preferred
  • Bachelor’s degree in Nursing

Experience:

• Required
  • Five years of experience in Clinical Nursing
• Preferred
  • Three years of experience in Inpatient Utilization Review

Certification/Licensure:

• Required
  • Registered Nurse (RN), with authorization to practice in the State of Texas
• Preferred
  • Accredited Case Manager (ACM) through ACMA
  • Certified Case Manager (CCM) through CCMC