Utilization Review Registered Nurse
Job Summary
Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is a non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones.
Position Summary
Wage: 28.09-44.81 On-site. This full-time (0.9 status or 36 hours per week) position ensures the medical necessity for hospital services, admissions and continued stay are met per specific Medicare and commercial payor guidelines.
Responsibilities
- Develops and implements effective utilization review functions resulting in maintaining an average length of stay that is financially justified for hospital operations.
- Reviews all inpatient and observation admissions within 24 hours for appropriateness based on approved criteria and standards, Monday through Friday. All weekend admissions are reviewed on the following Monday.
- Contacts physicians as required for information to justify admission or continued stay the same day of questionable stay.
- Refers all cases where necessity for admission is questionable or potential for denial is identified to the attending physician or his/her designee for appropriate action after notifying the Discharge Planning/Social Services manager.
- Develops and maintains a system to monitor and review certification completion.
- Maintains complete and accurate documentation which reflects the status of hospital utilization, numbers and categories of cases reviewed, and denials by fiscal intermediaries.
- Documents and reports back follow-up.
- Reviews and follows through the appeal process for patient stay denials.
Benefits
- Comprehensive benefits for qualifying full-time and part-time employees.
- Health insurance, dental insurance, vision insurance, life insurance, a 403(b)-retirement plan, and generous paid time off.
- Additional benefits for those qualifying include: Flexible Spending Account, Employee Assistance Program for mental health, Education Loan Program, Community discounts including the Prairie Lakes Wellness Center.
Pay
Wage: 28.09-44.81 On-site. This full-time (0.9 status or 36 hours per week) position ensures the medical necessity for hospital services, admissions and continued stay are met per specific Medicare and commercial payor guidelines.
Schedule
On-site. This full-time (0.9 status or 36 hours per week) position ensures the medical necessity for hospital services, admissions and continued stay are met per specific Medicare and commercial payor guidelines.