RN Utilization Review, Frazier Rehab Institute

UofL Health•Louisville, KY

13h•Onsite

About The Position

The RN Utilization Review position at Frazier Rehab Institute supports Utilization Management functions by conducting admission and concurrent reviews, evaluating medical necessity, and helping ensure patients receive care at the appropriate level. The role follows established criteria, policies, and Utilization Management leadership oversight, and uses current MCG criteria to review admissions, continued stays, and discharges. It includes screening cases against payer-specific guidelines, sending admission and continued-stay reviews, processing denials and retrospective reviews, and documenting clinical information and authorization details in case management software. The nurse collaborates with physicians, case managers, payors, and interdisciplinary team members to support timely care, appropriate resource use, optimal patient outcomes, and financial accountability. The role also addresses barriers and care-process delays, assists with billing and payer issues, identifies compliance concerns, advocates for patients and families, and educates physicians, patients, and staff about payer, financial, documentation, and compliance matters. The position requires maintaining confidentiality, following applicable policies and regulatory requirements, and participating in ongoing competency validation and regulatory education. UofL Health is a regional academic health system with five hospitals, four medical centers, nearly 200 physician practice locations, more than 700 providers, and over 12,000 team members. Its mission is to deliver patient-centered care.

Requirements

ADN or Bachelor of Science in Nursing; a bachelor's degree in business, Health Care Administration, or equivalent is acceptable if the employee enrolls in a BSN program within one year of employment and completes it within three years.
Two years of experience as an RN.
Active Kentucky Registered Nurse License or a compact license with privileges to work in Kentucky.
MCG Care Guidelines Specialist-ISC/GRC/Behavioral Health certification required within 12 months of hire.
Ability to adjust priorities quickly, organize multiple tasks, and work interdependently with staff at multiple levels.
Strong attention to detail, organizational, interpersonal, and communication skills, and innovative problem-solving skills.
Ability to maintain competency in care management and utilization management principles and current knowledge of commercial and government payers and relevant Joint Commission regulations, guidelines, and criteria.
Knowledge of state laws, CMS Conditions of Participation, and TJC standards for care management and utilization management.
Knowledge of service lines; sound nursing judgment; adherence to professional conduct and RN scope of practice.
Ability to adjust work hours based on departmental and organizational needs as determined by the director or manager of care coordination or the CNO.
Ability to communicate effectively verbally and in writing.
Ability to think critically through complex patient situations, process improvements, and evidence-based practice, and to assist others in developing clinical reasoning skills.
Ability to break down problems or tasks and identify causes and consequences using one's knowledge and experience.
Proficiency in Microsoft Word, Excel, and Outlook; basic computer skills, including electronic medical records; and capacity to learn other relevant systems and databases.
Commitment to service, organizational values, professionalism, confidentiality, safety standards, teamwork, and customer service.

Nice To Haves

Bachelor of Science in Nursing is preferred.
One additional year of case management or utilization management experience is preferred.
Case Management Certification (ACM, ANCC-Nurse Case Manager, or CCM) is preferred.

Responsibilities

Conduct timely admission and concurrent utilization reviews for designated medical services, including observation and inpatient cases.
Use current MCG criteria to assess medical necessity for admission, continued stay, and discharge, and document clinical information in case management software.
Evaluate medical records for process delays affecting timely care and collaborate to ensure appropriate resources are used.
Support appropriate admission-status decisions in accordance with regulatory and reimbursement requirements of commercial and government payers.
Communicate with third-party payors, provide pertinent clinical information, and document authorization numbers and approved lengths of stay.
Advocate for patient and family needs respectfully, non-judgmentally, and confidentially.
Serve as a resource to physicians on clinical management and financial issues and assist with improving care-delivery efficiency and reducing barriers to service.
Review cases for potential OIG Workplan audit and compliance issues, report concerns, and recommend action to appropriate departments.
Refer unresolved cases involving insufficient intensity of service or severity of illness to the appropriate manager, director, CAO, or medical director.
Educate physicians, patients, and staff about payors, financial matters, documentation, and potential compliance issues.
Investigate and respond to billing concerns from the Business Office, Health Information Management, Admitting, and other sources; resolve financial and billing issues, including patient status, payer source, denials, appeals, and system issues.
Develop cooperative working relationships with third-party reviewers to facilitate timely responses for patient accounts.
Attend monthly departmental staff communications meetings and serve on committees or projects as needed.
Participate in educational programs and activities to support professional growth and maintain competency.
Comply with company policies, standards of conduct, HIPAA privacy and security requirements, and confidentiality expectations.
Perform other duties as assigned.
Collaborate with team members and provide effective customer service to physicians, patients, residents, visitors, staff, and the broader health care community.