RN Utilization Review

Baptist Memorial Health Care•Memphis, TN

32d

About The Position

The Utilization Review Nurse is responsible for evaluating the medical necessity and appropriateness of healthcare services and treatment as prescribed by utilization review standards. The UR Nurse works with providers, insurance companies and patients to ensure cost-effective and appropriate care. Areas of work include status management, medical necessity reviews, verification of authorization, resource utilization, and denial prevention.

Requirements

RN with 3 years of clinical experience
Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills.
Problem solving; and knowledge of governmental regulations.
RN

Nice To Haves

RN with Case Management or Utilization Review experience in a hospital or payer setting
BSN or MSN
RN;CCM;ACM

Responsibilities

Completes and enters inpatient and observation admission review against standard criteria per payer guidelines
Prioritizes observation case review
Assists with level of care in collaboration with attending provider
Enters working diagnosis-related groups (DRGs) in the electronic medical record
Submits clinical information to payer per payer requirements
Completes continued stay reviews every 3 days or more often if required
Communicates with care coordinators for authorized days, level of care, medical necessity or other areas when indicated
Communicates with physician advisors related to status concerns or denials
Updates auth/cert screen in the electronic medical record
Works assigned queues in the electronic medical record
Communicates with authorization coordinator
Communicates in-house high dollar case information
Completes assigned goals