Utilization Review RN

Job Summary and Responsibilities

As our Utilization Review RN, you will meticulously review medical records to confirm appropriate admission status and continued hospitalization, utilizing established criteria and critical thinking. You'll work hand-in-hand with Concurrent Denial RNs to identify the root causes of denials and implement proactive prevention strategies. This role is essential for collaborating with Patient Access to verify payer sources, documenting interactions, and obtaining inpatient authorization from insurance providers, ensuring seamless patient journeys and financial integrity. Every day you will conduct admission, concurrent, and post-discharge reviews, ensuring compliance with utilization review principles, hospital policies, and external regulatory agencies like PRO and Joint Commission. You'll identify deficiencies with providers regarding accurate patient status orders, and facilitate timely communication with all stakeholders—physicians, payers, and Care Coordinators—regarding review outcomes. Your expertise will be vital in supporting the second-level physician reviewer, coordinating peer-to-peer discussions, and documenting a working DRG on each assigned patient at initial review. To be successful in this role, you will possess critical thinking and problem-solving skills, exceptional professional communication abilities, and a strong collaborative spirit. You must thrive in a fast-paced, self-directed environment, demonstrating the ability to prioritize work, delegate effectively, and manage time efficiently. Your meticulous attention to detail, knowledge of a managed care and payer environment, and proficiency in applying clinical guidelines will be key to your success and our organization's commitment to quality care and fiscal responsibility.

• Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking.
• Reviews include admission, concurrent and post discharge for appropriate status determination.
• Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
• Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
• Collaborates with facility RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Job Requirements

Required

• Associate's Degree in Nursing
• Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of one (1) year experience.
• RN License; Current state nursing licenses or valid RN license from a participating state in the National Licensure Compact.
• Ability to pass annual Interrater reliability test for Utilization Review product(s) used.
• Understand how utilization management and case management programs integrate.
• Knowledge of CMS standards and requirements.

Preferred

• Bachelor's Degree in Nursing (BSN) or related healthcare field. At least five (5) years of nursing experience.
• Certified Case Manager (CCM), Accredited Case Manager (ACMRN), or UM Certification
• Proficient in application of clinical guidelines (MCG/InterQual).
• Knowledge of managed care and payer environment.