RN, Senior Utilization Review Quality
About The Position
The RN, Senior Utilization Review Quality supports the VUR team and its leadership by independently reviewing accounts handled by entry-level and senior-level Revenue Cycle team members. The role identifies quality improvement opportunities and recommends actions to operational and executive leaders. It also supports ongoing training, education, action plans, and onboarding, including user provisioning as needed. The position reviews work across multiple clients and host systems, assesses quality assurance processes, and evaluates VUR policies and procedures. It conducts root cause analysis, documents review findings and processes, identifies operational, compliance, and quality risks, and prepares reports and recommendations for leadership. This is a remote position, but the employee must be willing and able to travel to and work onsite at client, temporary, or corporate offices as business needs require. The VUR department operates seven days per week from 8:00 a.m. to 10:00 p.m.; candidates must be able to work within those hours, including weekends as needed.
Requirements
- Bachelor’s degree or equivalent experience in Nursing or a related field.
- Current unrestricted RN license.
- At least three years of nursing experience in an acute care environment.
- Current working knowledge of quality improvement processes.
- Excellent interpersonal, communication, and negotiation skills when interacting with physicians, payors, and healthcare team colleagues.
- Commitment to exceptional customer service.
- Ability to communicate ideas effectively verbally and in writing.
- Strong clinical assessment, organization, and problem-solving skills.
- Ability to assess and identify appropriate internal and community resources for an assigned caseload and collaborate with healthcare teams, providers, and payors to achieve desired patient, quality, and financial outcomes.
- Ability to prioritize and organize information and complete multiple tasks effectively in a fast-paced environment.
- Resourcefulness and ability to work independently.
- Inquisitiveness and openness to innovation, including AI, to explore better processes and improve patient and client experiences.
- Willingness and ability to work within the VUR department’s scheduled hours of 8:00 a.m. to 10:00 p.m., seven days per week, including weekends as needed.
- Willingness and ability to travel to and work onsite at client, temporary, or corporate office locations as business needs require.
- Must reside and be authorized to work in the United States.
Nice To Haves
- RN compact license.
- Utilization review or discharge planning experience.
- Recent experience or working knowledge of medical necessity review criteria.
Responsibilities
- Mentor UR Quality Specialists and UR team members to develop and improve their quality review skills.
- Assess the Quality Assurance process, identify opportunities to increase efficiency, and bring them to leadership’s attention.
- Evaluate operational and management VUR policies and procedures for entry-level and senior-level teams, providing input into the annual review workplan.
- Perform quality reviews across multiple clients and host systems, including root cause analysis of audit findings, quality assurance audits, and utilization management denials.
- Coordinate with service line leaders and upper-level leadership to identify risk areas and help develop quarterly and annual review plans.
- Develop a thorough understanding of business processes in scope for assigned reviews and document those processes.
- Conduct account-level reviews of entry-level and senior-level team members’ work to assess consistency with best practices and the implementation and effectiveness of policies and procedures.
- Review compliance with policies, procedures, workflows, and other applicable requirements.
- Identify and document operational, compliance, and quality risks and recommend ways to mitigate them.
- Prepare and present quality reports of review findings and recommendations to direct leadership for review and approval.
- Participate in pre-review and post-review meetings, providing support and recommendations on issues presented.
- Ensure recommendations from past reviews are implemented in current review processes.
- Maintain current knowledge of laws and regulations regarding medical necessity, clinical documentation, compliance standards, reviewing, and related clinical or business matters.
- Assist with continued training, education, and action plans in partnership with the Leadership Team.
- Support onboarding, including user provisioning as required, in partnership with the Leadership Team.
Benefits
- Bonus incentives and quarterly and annual incentive programs.
- Paid professional certifications.
- Tuition reimbursement.
- Comprehensive benefits package, including healthcare, time off, retirement, and well-being programs.
- Career advancement and professional development opportunities.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
