UTILIZATION REVIEW NURSE-ED (PT NIGHTS)

Responsibilities

• Conduct thorough reviews of patient cases in the Emergency Department to assess the necessity and appropriateness of admissions, continued stays, and level of care.
• Utilize clinical knowledge and evidence-based guidelines to make determinations regarding the medical necessity of services.
• Work closely with physicians, nurses, and other healthcare professionals to gather necessary information and discuss care plans.
• Communicate with insurance providers to obtain authorization for treatments and services, ensuring compliance with payer requirements.
• Proactively facilitate throughput of all patients by monitoring for census peaks including surgical and procedural patient placement.
• Maintain accurate and detailed documentation of case reviews, decisions, and communications with healthcare providers and insurance companies.
• Prepare and submit reports as required, including utilization review reports and compliance documentation.
• Participate in quality improvement initiatives to enhance the efficiency and effectiveness of care provided in the Emergency Department.
• Analyze utilization patterns and outcomes to identify opportunities for improvement and contribute to the development of best practices.
• Ensure adherence to hospital policies, payer guidelines, and regulatory requirements related to utilization management.
• Stay informed about changes in healthcare regulations and payer requirements to ensure ongoing compliance.

Requirements

• Minimum of 3 years of clinical experience in an Emergency Department setting.
• Prior experience in utilization review or case management is preferred.
• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal skills for effective collaboration with healthcare providers and insurance representatives.
• Proficiency in electronic health record (EHR) systems and utilization review software.
• Ability to work independently and manage multiple tasks efficiently in a fast-paced environment.
• Knowledge of InterQual and/or MCG and local and national coverage determinations.

Qualifications

• Active Registered Nurse (RN) license in the State of Illinois.
• Associates Degree of Nursing (AND)*
• All new RN’s starting on or after 1/1/25 must complete their Bachelors of Science in Nursing within three years.
• Bachelors Degree in Nursing (BSN) from an accredited institution or higher degree*

Skills

• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal skills for effective collaboration with healthcare providers and insurance representatives.
• Proficiency in electronic health record (EHR) systems and utilization review software.
• Ability to work independently and manage multiple tasks efficiently in a fast-paced environment.
• Knowledge of InterQual and/or MCG and local and national coverage determinations.

Benefits

• No benefits are mentioned in the job posting.

Pay

USD $40.90 - USD $54.20 /Hr

Schedule

No schedule details are provided in the job posting.