Swing Shift RN Clinical Review Management

St. Luke's Health System•Boise, ID

11d•Onsite

About The Position

Swing Shift RN Clinical Review Management At St. Luke’s, our dedicated team of Clinical Review Nurses strive to build a positive, supportive, and inclusive culture that delivers exceptional patient experiences. This role involves reviewing the medical necessity of admission, continued hospitalization, length of stay, and any potential denial of payment issues. It requires applying established criteria and clinical expertise to interpret clinical criteria to determine medical necessity of services, including performing Medicaid and Medicare reviews. The position also involves providing feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Results of reviews are communicated to the primary care team, specialty providers, vendors, and members in adherence with regulatory and contractual requirements.

Requirements

Current RN license in Idaho
Bachelor of Nursing or Associates of Nursing Degree
3 years of RN or utilization management experience (BSN) or 5 years of RN or utilization management experience (ASN)

Responsibilities

Reviews the medical necessity of admission, continued hospitalization, length of stay, and any potential denial of payment issues.
Applies established criteria and employs clinical expertise to interpret clinical criteria to determine medical necessity of services.
Performs Medicaid and Medicare review.
Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care.
Communicates results of reviews to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements.