Commercial Utilization Review Nurse (RN)
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About The Position
The Utilization Review (UR) Nurse (initial clinical reviewer) is a registered nurse (RN) or health professional (licensed practical nurse (LPN) or licensed vocational nurse (LVN)), who possesses an active, current, unrestricted, and valid professional license or certification in each state or territory in the United States (U.S.) that the organization provides utilization management (UM) services, if the UR RN is reviewing clinical cases in that state. During the initial screening process, UR RN's are available to non-clinical administrative staff while non-clinical administrative staff perform initial screening. UR RN reviews and evaluates clinical cases for appropriateness against established criteria and published medical evidence. The UR Nurse, using clinical and operational knowledge, assesses needs and coordinates resources within and outside the benefit plan to promote optimal health benefits and outcomes (both clinical and financial). Initial clinical reviewers have the appropriate clinical background to render decisions requiring clinical judgment and experience. The UR Nurse (initial clinical reviewer) may assist in the notification process for non-certifications. Initial clinical reviewers must have appropriate clinical support and do not issue non-certifications. The UR Nurse reviews requests for medical services and consults or refers to a Medical Director (licensed doctor of medicine or doctor of osteopathic medicine; licensed health professional in the same licensure category as the ordering provider; or health professional with the same clinical education as the ordering provider in clinical specialties where licensure is not issued) for those clinical cases that require additional expertise. Measures and reviews performance outcomes, proposes, and implements improvement processes and system enhancements to achieve desired results. Identifies appropriate resources and demonstrates knowledge in managing each case and maintains accurate records and provides timely verbal and written reports as directed.
