RN-Utilization Review

About the Role

Manages the care for a specific population; facilitates the safe transition of patients throughout the continuum of care for appropriate utilization of resources, service delivery, and compliance with federal and other payer requirements. Provides early assessment of transitional needs identified during hospitalization, illness, and/or life situation. Performs other duties as assigned.

Responsibilities

• Utilization Review
• Discharge planning
• Readmission Reduction Participation
• Payer Communication and denial reduction
• Completes assigned goals

Requirements

• RN with at least one (1) year of clinical experience
• Diploma or Associate Degree in Nursing
• RN licensure
• Critical thinking skills, communication, organization, interpersonal, and computer skills
• Problem-solving abilities
• Knowledge of governmental regulations

Qualifications

• Preferred: RN with 3 years of clinical experience with Case Management experience in a hospital or payer setting
• Preferred: BSN or MSN
• Preferred: Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification
• Preferred: Advanced knowledge of payer requirements