RN Utilization Review II-Hybrid-FT/Days (8a-430p)

Centra Health•Lynchburg, VA

4d•Hybrid

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 involving Medicare, Medicaid, and other insurance payors. The nurse communicates with clinical disciplines, commercial payers, patient access, patient financial services, the Physician Advisor, and other staff members.

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 a current multistate/compact license.
AHA BLS Provider certification.

Responsibilities

Perform initial, concurrent, and retrospective reviews of assigned patients for severity of illness and intensity of service.
Interpret InterQual and Milliman and Robertson criteria to determine whether patients meet admission and continued-stay criteria.
Provide accurate and complete account authorization information and details in plan notes.
Complete admission reviews on the business day following a 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 the confidentiality of patients, physicians, and team members, and comply with applicable federal and state guidelines and regulations.
Meet the budget length-of-stay goal.
Perform other duties as assigned or requested; job specifications may be modified or updated at any time.