Utilization Review Nurse Jobs

Job Summary:

The Utilization Review Registered Nurse (RN) provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with the health plan, provider utilization and/or care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates as a team to ensure that medical records support the level of services being delivered.

QUALIFICATIONS

• CCN preferred.
• Bachelor’s degree required.
• Licensure as a registered nurse required.

Essential Functions:

• Performs initial, concurrent, discharge and retrospective reviews.

• Uses evidence-based medical guidelines to determine the medical appropriateness of inpatient and outpatient services

• Assesses patient needs

• Uses knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients

• Identifies, escalates and resolves complex cases or issues as required.

• Facilitates authorization process for admissions and continued stays.

• Uses knowledge of nursing process and pathophysiology to anticipate discharge needs.

• May participate in discharge planning through discussions with the care team as needed.

• Communicates issues or trends with specific entities, providers or payors to the appropriate leadership.

• Provides support to complex cases or escalations within scope of licensure or refers them to appropriate leadership.

• Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.

• Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies, and procedures to continuously enrich care coordination efforts and ensure evidence-based processes are utilized. Performs service recovery efforts to support provider and member satisfaction.

PHYSICAL DEMANDS

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools, or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.

• The employee must be able to lift and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.

• The employee must be able to stand and/or walk at least five hours per day.

WORK ENVIRONMENT

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.