Utilization Review WEO RN

CoxHealth•Remote Missouri, MO

2d•Remote

About The Position

The Utilization Review Nurse RN collaborates with physicians and members of the multidisciplinary team to facilitate progression of care. The nurse monitors patient progress and intervenes as appropriate to ensure the plan of care and services provided are patient-focused, high quality, evidence-based, appropriate to patient needs, efficient, and cost-effective. The role conducts concurrent medical record reviews for medical necessity and level of care using nationally recognized acute care indicators and criteria approved by medical staff, accrediting bodies, and state agencies. The nurse prospectively or concurrently determines the appropriateness of inpatient or observation services by reviewing medical documentation, medical guidelines, and insurance benefits, and communicates information to payers in accordance with contractual obligations. The nurse also serves as a physician resource, providing education and information on resource utilization, local and national coverage determinations, and hospital admission criteria.

Requirements

Graduate of an accredited school of nursing.
Minimum of 3 years of hospital experience.
Current RN license active in the state of Missouri.
Excellent interpersonal skills, including the ability to be genuine and empathetic.
Excellent verbal and written communication skills, with attention to detail.
Computer skills.
Ability to interact professionally and contribute to the interdisciplinary team.

Nice To Haves

Bachelor of Nursing degree.
Knowledge of InterQual Level of Care Criteria and/or Milliman Care Guidelines.
Knowledge of local and national coverage determinations.
Certified Case Manager.

Responsibilities

Collaborate with physicians and the multidisciplinary team to facilitate progression of care.
Monitor patient progress and intervene as appropriate to support patient-focused, high-quality, evidence-based, appropriate, efficient, and cost-effective care.
Conduct concurrent medical record reviews for medical necessity and level of care using approved, nationally recognized acute care indicators and criteria.
Prospectively or concurrently determine the appropriateness of inpatient or observation services by reviewing medical documentation, medical guidelines, and insurance benefits.
Communicate information to payers in accordance with contractual obligations.
Provide physicians with education and information on resource utilization, local and national coverage determinations, and hospital admission criteria.