RN - Utilization Review - Utilization Review

University of Mississippi Medical Center • Jackson, MS

12h • Onsite

About The Position

RN-Utilization Review is accountable to perform utilization management services for designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the utilization management process to the appropriate manager.

Requirements

• One (1) year of nursing experience in an inpatient setting.
• Valid RN license.
• Knowledge of utilization review, discharge planning, case management, and managed care reimbursement.
• Strong working knowledge of medical procedures, diagnoses, and procedure codes, including ICD-10, CPT, and DSM-IV.
• Excellent interpersonal, verbal, written communication, and negotiation skills.
• Ability to gather data, prepare reports, and identify process improvements.
• Able to work independently, exercise sound judgment, and apply medical necessity guidelines with minimal supervision.
• Committed to quality patient care, customer service, safety, cost efficiency, and continuous quality improvement (CQI).
• Proficient in the use of computers and related software applications.

Responsibilities

• Performs prospective, concurrent, retrospective, and denials review for individual cases, including benefit coverage, medical necessity, appropriate level of care, and mandated services.
• Assists in collecting and reporting financial and performance indicators, including case mix, length of stay, cost per case, resource utilization, readmission rates, denials, and appeals.
• Uses data to drive decisions and implement performance improvement strategies related to case management, including fiscal, clinical, and patient satisfaction outcomes.
• Collects and analyzes variances from the plan of care and collaborates with physicians and the healthcare team to address issues and improve outcomes.
• Applies clinical appropriateness criteria to monitor admissions and continued stays, identifies at-risk populations, and refers cases to the care management physician advisor as needed.
• Communicates with third-party payers to facilitate reimbursement certification, resolves payor issues, and completes utilization management and quality screening for assigned patients.
• Works collaboratively with the interdisciplinary care team to ensure timely, appropriate patient management, remove barriers to care, and proactively address delays or discharge obstacles.
• Ensures safe, high-quality care in compliance with policies, procedures, and standards, while managing time, supplies, productivity, and accuracy within budgetary guidelines.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed