[Hiring] Registered Nurse - Utilization Review @HonorHealth

Role Description

The Utilization Review RN Specialist reviews and monitors utilization of health care services with the goal of maintaining high quality cost-effective care. Ensures appropriate level of care through comprehensive review for medical necessity of extended stay, outpatient observation, and inpatient stays and the utilization of ancillary services. Responsible for coordinating and conducting medical necessity reviews for all Medicare, AHCCCS, Self-pay, and all other payers, upon admission and concurrently throughout the admission.

• Reviews clinical documentation and facilitates modifications (as needed) to ensure that documentation accurately reflects the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients.
• Performs initial and concurrent reviews on all patients entering the health care continuum.
• Facilitates the delivery of services to patients and families through effective utilization of available resources.
• Performs medical record reviews, as required by payer.
• Interfaces with Care Management team to provide information regarding quality outcome measurements (such as timeliness and appropriateness of services).
• Collaborates with physicians, case managers, payers and others to appeal individual denials and trended issues related to contract guidelines.
• Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.
• Initiates chart reviews, conducts follow-up reviews, and rounds on patients to ensure continuity of UR reviews.
• Maintains a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions.
• Notifies attending physicians and house staff or other appropriate staff of documentation issues requiring clarification.
• Determines qualifications for hospital level of care based on set criteria.
• Performs other duties as assigned.

Qualifications

• Associates in Nursing from an accredited NLN/CCNE institution (Required)
• Bachelors in Nursing from an accredited NLN/CCNE institution (Preferred)
• 1 year experience in UR/UM or Case Management (Required)
• 3 years Registered Nurse in an acute care setting (Required)

Requirements

• Registered Nurse (RN) - License State And/Or Compact State Licensure (Required)
• Certified Case Manager - Certification Certified Case Management (ACM) Case Management Certification (Preferred)

Benefits

• Seeking Applicants That Can Work at Least 8 Shifts per Month