Purpose of Position and Scope of Responsibility
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.
Principal Accountabilities/Responsibilities
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
Minimum Qualifications
Minimum Education
Description Minimum Required Preferred/Desired
Diploma or Associate Degree in Nursing
BSN or MSN
Minimum Experience
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
Minimum Licensure, Registration, Certification
Description Minimum Required Preferred/Desired
RN
RN;CCM;ACM
Desired Qualifications
Desired Education
Education
Description Minimum Required Preferred/Desired
Diploma or Associate Degree in Nursing
BSN or MSN
Desired Experience
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
Desired Licensure, Registration, Certification
Description Minimum Required Preferred/Desired
RN
RN;CCM;ACM
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