Registered Nurse Utilization Review

Nevada System of Higher Education•Naperville, IL

1d•Onsite

About The Position

Under minimal supervision and using clinical knowledge, the RN Utilization Review completes utilization review activities to ensure appropriateness of admission and continued stay and to reduce financial risk to the patient and hospital. Works on complex reviews. Communicates results of reviews to payers and other third parties for certification of hospitalization and subsequent payment. Acts as a clinical resource for the Coordinator Utilization Review.

Requirements

Associates Degree Nursing Required
2 Years of utilization review and/or clinical experience
2 Years of utilization review experience
Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Required

Nice To Haves

Bachelors Degree Nursing Preferred

Responsibilities

Performs concurrent clinical reviews for utilization review using appropriate screening criteria; completes necessary review as identified and required by payers until patient discharge. Reviews must be thorough and completed on a timely basis.
Communicates with team members including physicians, case managers, social workers, Utilization Review Coordinators, and nurses, regarding utilization issues.
Performs continual tracking of in-house patient status; communicates with appropriate team members and third parties regarding status issues.
Tracks denials and reports the issues through the appropriator channels; follows through with Coordinator Clinical Denials to appeal appropriate denials.
Performs continual review of in-house observation patients.
Communicates with case management regarding patient status and issues.
Identifies and tracks Avoidable Days.
Refers case to physician advisor as necessary.
When appropriate obtains orders for status changes from physicians and documents the order in the electronic medical record.
Acts as a clinical resource for Coordinator Utilization Review.