Inpatient Utilization Review RN - 1.0FTE
About The Position
The Inpatient Utilization Review RN is a key member of the healthcare team responsible for ensuring the appropriate utilization of hospital resources through concurrent review, medical necessity evaluation, payer communication, and regulatory compliance activities. This role collaborates with physicians, nursing staff, case management, and third-party payers to support optimal patient outcomes while ensuring appropriate admission status, level of care, and reimbursement. The Inpatient Utilization Review RN also assists with care coordination and discharge planning activities to support efficient patient progression throughout the continuum of care.
Requirements
- Graduate of an accredited nursing program.
- Current Wisconsin Registered Nurse (RN) license required.
- Minimum of three (3) years of clinical nursing experience in acute care required.
- Familiarity with Critical Access Hospital regulations required.
- 3 years acute care experience
Nice To Haves
- Bachelor’s degree in nursing (BSN) preferred.
- Previous experience in utilization review, case management, care coordination, revenue cycle, or discharge planning preferred.
- Experience working with Medicare, Medicaid, and commercial insurance plans preferred.
- Certified Case Manager (CCM), Accredited Case Manager (ACM), or utilization review certification preferred.
Responsibilities
- Perform concurrent reviews of inpatient, observation, swing bed, and other applicable patient stays to evaluate medical necessity and appropriate level of care.
- Apply established criteria (InterQual) to support admission status and continued stay determinations.
- Collaborate with providers to obtain documentation necessary to support medical necessity and reimbursement.
- Identify opportunities to improve documentation and ensure accurate patient status designation.
- Monitor length of stay and identify barriers to timely progression of care.
- Obtain and maintain required payer authorizations for admissions, continued stays, procedures, and post-acute services.
- Serve as liaison between the hospital, physicians, and insurance providers regarding utilization review activities.
- Assist in the appeal process for denied services and work collaboratively with interdisciplinary teams to reduce avoidable denials.
- Maintain current knowledge of payer requirements and reimbursement regulations.
- Collaborate with patients, families, providers, nursing staff, and community resources to facilitate safe and effective transitions of care.
- Assist with discharge planning activities including referrals to post-acute services, home health agencies, rehabilitation facilities, and durable medical equipment providers.
- Identify barriers to discharge and coordinate interventions to support timely patient transitions.
- Educate patients and families regarding care transitions, insurance requirements, available resources, and post-discharge services.
- Promote patient understanding and engagement in discharge and follow-up plans.
- Maintain complete, accurate, and timely documentation in the electronic health record.
- Ensure compliance with CMS Conditions of Participation, Critical Access Hospital regulations, payer requirements, and organizational policies.
- Participate in audits, quality improvement initiatives, and regulatory reviews as needed.
- Track and report utilization review metrics, trends, and opportunities for improvement.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
