UTILIZATION REVIEW NURSE - RN

Position Summary

The Utilization Review Registered Nurse (UR RN) is a key contributor to the delivery of appropriate, efficient, and cost-effective patient care. Working collaboratively within a multidisciplinary team, the UR RN conducts comprehensive reviews of clinical documentation, assesses medical necessity, and coordinates with healthcare providers and payers to support optimal patient outcomes and resource management.

Job-specific Responsibilities

• Supports and communicates the Mission, Vision, and Values of Nexus Health Systems
• Upholds the Standards of conduct and corporate compliance
• Demonstrates honest behavior in all matters. Complies with all Federal and State laws and regulations
• Maintains the privacy and security of all confidential and protected health information
• Collaborates effectively with colleagues and other departments to ensure seamless service delivery
• Educates treatment teams on comprehensive documentation practices to reflect patient status and treatment plans accurately
• Collaborates with case management to address discharge planning, expected length of stay (ELOS), and potential barriers
• Advocates for patients by ensuring access to necessary services and facilitating transitions to appropriate levels of care
• Ensures all activities adhere to healthcare regulations and organizational policies
• Participates in quality improvement initiatives to enhance service delivery
• Promotes a culture of patient safety which results in the identification and reduction of unsafe practices
• Ensures adherence to applicable state and federal regulations, accreditation standards, and payer requirements
• Participates in quality improvement, utilization management committees, and risk management activities
• Performs ongoing quality assurance audits to evaluate the effectiveness of utilization review processes
• Stays informed about changes in healthcare policies, regulations, and best practices related to utilization management
• Completes annual education requirements
• Maintains competency, as evidenced by completion of competency validation requirements
• Maintains competency and knowledge of current standards of practice, trends, and developments
• Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices
• Attends departmental meetings, in-services, and training sessions as required
• Pursues relevant certifications to enhance professional development and expertise in utilization review
• Promotes stewardship of hospital resources while ensuring quality patient care
• Manages denials and appeals processes, including evaluating root causes and developing strategies to minimize occurrences
• Collaborates with internal departments to address unfunded days and work towards overturning denials
• Facilitates authorization requests for level-of-care changes and insurance updates
• Analyzes utilization data to identify trends and opportunities for cost savings

Qualifications

• Associate Degree in Nursing (ADN) from an accredited institution required
• Bachelor of Science in Nursing (BSN) from an accredited institution preferred
• Minimum of 2 years of clinical nursing experience in an acute care setting
• At least 3 years of experience in utilization review, case management with complex medical/surgical and/or behavioral health cases
• Experience with behavioral health services is advantageous
• 2-3 years’ experience with InterQual or MCG preferred

Skills

• Strong analytical and critical thinking abilities
• Excellent written and verbal communication skills
• In-depth knowledge of healthcare regulations, payer guidelines, and accreditation standards
• Ability to work independently and collaboratively within a team environment
• Effective time management and organizational skills
• Strong computer skills with demonstrated proficiency in electronic health records (EHRs) and utilization management software systems
• Preferred experience with Meditech and Microsoft Office applications, including Outlook, Teams, Excel, Word, and SharePoint