Registered Nurse - Utilization Review Per Diem
About The Position
The Utilization Review RN Specialist reviews and monitors health care service utilization to support high-quality, cost-effective care. The role ensures the appropriate level of care through comprehensive medical-necessity reviews of extended stays, outpatient observation, inpatient stays, and ancillary services. The specialist coordinates and conducts medical-necessity reviews for Medicare, AHCCCS, self-pay, and other payers upon admission and throughout the admission. This position is per diem and seeks applicants able to work at least eight shifts per month. It is a virtual role based in Arizona on the Case Management team, with a day shift.
Requirements
- Associate degree in Nursing from an accredited NLN/CCNE institution required, or Bachelor’s degree in Nursing from an accredited NLN/CCNE institution preferred.
- At least 1 year of experience in utilization review, utilization management, or case management required.
- At least 3 years of registered nurse experience in an acute care setting required.
- Registered Nurse license in the state of practice and/or compact state licensure required.
Nice To Haves
- Bachelor’s degree in Nursing from an accredited NLN/CCNE institution.
- Certified Case Manager certification, such as ACM or another case management certification.
Responsibilities
- Review clinical documentation and facilitate modifications as needed so documentation accurately reflects the level of service provided and severity of illness, in compliance with applicable regulations.
- Perform initial and concurrent reviews for patients entering the health care continuum.
- Facilitate services for patients and families through effective use of available resources.
- Perform medical record reviews as required by payers.
- Coordinate with the Care Management team regarding quality outcome measures, including timeliness and appropriateness of services.
- Collaborate with physicians, case managers, payers, and others to appeal individual denials and address trends related to contract guidelines.
- Work with medical records, finance, and physician groups to develop systems that support complete documentation for data reporting.
- Initiate chart reviews, conduct follow-up reviews, and round on patients to ensure continuity of utilization review.
- Maintain a system to identify admissions by diagnosis, DRG classification, or other admission categories.
- Notify attending physicians, house staff, or other appropriate staff of documentation issues requiring clarification.
- Determine qualifications for hospital-level care based on established criteria.
- Perform other duties as assigned.
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What This Job Offers
Education Level
Associate degree
