Registered Nurse Utilization Review

St. Luke's University Health Network•Allentown, PA

1d•Onsite

About The Position

The Registered Nurse Utilization Review will be responsible for substantiating medical necessity and clinical appropriateness of services in order to achieve quality outcomes and ensure appropriate reimbursement. This role involves screening medical records, performing various types of reviews, communicating with payers, and ensuring patient status and levels of care are appropriate. The position also requires documentation, compliance with regulations, and collaboration with various internal teams and external entities.

Requirements

Graduate of professional nursing program.
Registered Nurse with current license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity.
NJ RN licensure required upon hire.
At least 3 years of clinical experience as a registered nurse in an acute setting.

Nice To Haves

Advanced degree preferred.
2 years of hospital or payor based utilization review experience preferred.
Knowledge of Interqual and Milliman criteria preferred.
Care Management certification preferred.

Responsibilities

Screens selected medical records in accordance with contractual agreements and departmental policies for appropriateness of admission; performing initial, continued stay, and retrospective reviews if applicable.
Submits initial reviews and updates using established criteria and communicates with payers as appropriate, using established processes.
Utilize established processes with the Physician Advisors to manage second level and peer to peer reviews.
Ensure patient status and levels of care are appropriate on admission and prior to discharge.
Makes timely contact with payers and provides information as appropriate.
Documents all utilization review outcomes and activities appropriately in the medical record.
Complies with all applicable payer, state and federal regulations as well as The Joint Commission requirements regarding Care Management and Utilization Review processes.
Acts as resource for and provides updates to the care management staff and care team for issues related to utilization review processes.
Engages providers with concerns regarding medical necessity and appropriateness of services.
Escalate concerns related to medical necessity and appropriateness of services to the Physician Advisors.
Works collaboratively with the Denials Specialist and Physician Advisors to manage retrospective appeals and documents according to established policy.
Works collaboratively with the business office/finance to ensure proper reimbursement.