Utilization Review Nurse RN or LPN

Education

• Should have a high level of clinical knowledge and a current Arkansas licensure as a RN.
• Preferrably experienced in the use of ICD-CM and CPT coding systems.
• Skilled in the use of the computer and photocopier.
• Good people and phone skills required.

Training and Experience

• Should have past experience working with Medical Staff, patients, hospital associates and insurance companies.
• Must be capable of following verbal and written instructions.
• Should practice diplomacy in dealing with Medical Staff, patients, associates and insurance companies.
• Will participate in ongoing education through workshops, in service programs and updates from CMS, AFMC and other government and private agencies.

Job Knowledge

• Must be able to communicate verbally and in written format with the Medical Staff, review organizations, administration and others as indicated.
• Must be able to apply current nursing knowledge to determine appropriate acuity levels and appropriate care by chart review.

Safety Sensitive

No.

Description

• Should have the ability to work under pressure and in conditions of frequent interruptions.
• Needs considerable initiative and judgment while performing duties in an area where procedures are standardized but where frequent independent decisions are required.
• Help maintain a quality control system to assure effective utilization of hospital facilities and services.
• Assist in the promotion and maintenance of high quality care through review of clinical practices within the hospital based on pre-established criteria.
• The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, and promoting clinical best practice.
• Ensuring all patients receive “the right care, the right cost, right time, and in the right setting.”
• This position requires knowledge in the care of patients served as indicated: Infant to adolescence is 0 to 17 years, Adult is 18 years to 65 years and Geriatric is 65 years and above.

Physical Effort

• Sits at desk when he/she is not locating records and other various information for nurses, doctors, etc.
• Works in a well-lighted, air conditioned office.