RN Utilization Review II-Hybrid-FT/Days (8a-430p)
About The Position
The Utilization Review Nurse coordinates day-to-day admission criteria in relation to patients’ healthcare needs and organizational requirements. The role requires knowledge of regulatory requirements and compliance with Medicare, Medicaid, and other insurance payors. The nurse communicates and collaborates with clinical disciplines, commercial payers, patient access, patient financial services, the Physician Advisor, and other staff members. The position performs utilization reviews and supports appropriate clinical utilization, authorization processes, patient advocacy, and length-of-stay goals while maintaining patient and staff confidentiality and complying with federal and state guidelines and regulations.
Requirements
- Graduate of an accredited nursing program.
- Three years of experience in acute-care nursing.
- Computer skills.
- Excellent communication skills and ability to work collaboratively with other disciplines.
- Current, active registered nurse license in Virginia or current multistate/compact license.
- AHA BLS Provider certification.
Responsibilities
- Provide initial, concurrent, and retrospective reviews of assigned patients for severity of illness and intensity of service.
- Interpret InterQual and Milliman and Roberts criteria to determine whether patients meet admission and continued-stay criteria.
- Provide accurate and complete account authorization details in plan notes.
- Perform admission review on the business day following the patient's admission.
- Involve the Physician Advisor when physician-to-physician interaction is needed to achieve appropriate clinical utilization.
- Work collaboratively with the Physician Advisor to facilitate all aspects of the utilization management plan.
- Serve as a liaison to patient accounting and patient access regarding authorizations and claims.
- Communicate effectively with internal and external customers.
- Demonstrate commitment to customer satisfaction and patient advocacy.
- Maintain confidentiality of patients, physicians, and other team members, and comply with federal and state guidelines and regulations.
- Achieve the budget length-of-stay goal.
- Perform other duties as assigned or requested; job specifications may be modified or updated at any time.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
