Utilization Review Nurse - Full Time

Wilson Health•Sidney, OH

9d•Onsite

About The Position

Wilson Health is seeking a full-time Utilization Review Nurse to join their Case Management department. The Utilization Review (UR) Registered Nurse is responsible for conducting prospective, concurrent, and retrospective review of patient medical records to ensure appropriate utilization of hospital services, accurate patient status, and compliance with applicable payer, regulatory, and hospital requirements. The UR RN collaborates closely with physicians, nursing staff, case management, medical records, billing, and hospital leadership. The position plays an important role in supporting appropriate patient placement, timely documentation, quality outcomes, and reimbursement while helping ensure patients receive the right level of care in the right setting.

Requirements

Current, unrestricted Registered Nurse (RN) license in the applicable state
Graduate of an accredited nursing program
Clinical nursing experience sufficient to demonstrate strong assessment and critical-thinking skills.
Working knowledge of medical terminology, clinical documentation, and standards of care.
Strong written and verbal communication skills.
Ability to work independently, prioritize multiple responsibilities, and meet deadlines.
Proficiency with electronic medical records and standard computer applications.
Current, active, unrestricted Registered Nurse (RN) license in the State of Ohio required.
Must maintain all required licensure and certifications throughout employment.
Strong clinical assessment and critical-thinking skills.
Ability to interpret and analyze complex medical records.
Knowledge of inpatient versus observation status and appropriate level-of-care considerations.
Understanding of healthcare reimbursement and payer requirements.
Ability to identify incomplete or insufficient clinical documentation.
Excellent organizational and time-management skills.
Ability to communicate professionally with physicians, nurses, patients, families, payers, and hospital leadership.
Ability to maintain confidentiality and exercise sound professional judgment.
Comfortable working in an environment with limited resources and a broad range of patient needs.
Ability to adapt to changing priorities and assist with multiple functions when needed.

Nice To Haves

Case Management certification through ACMA, CMSA, or another recognized case management organization preferred.

Responsibilities

Perform medical necessity and level-of-care reviews for inpatient, observation, emergency, and other applicable services.
Review clinical documentation, physician orders, nursing documentation, diagnostic results, treatment plans, and patient progress to determine appropriateness of admission and continued stay.
Apply established utilization review criteria, payer-specific guidelines, Medicare requirements, and hospital policies.
Identify cases that may not meet medical necessity or level-of-care criteria and communicate concerns appropriately to physicians and the interdisciplinary care team.
Facilitate physician-to-physician or peer-to-peer reviews with payers when necessary.
Monitor patients concurrently throughout their hospital stay and identify barriers to continued hospitalization or discharge.
Communicate with physicians and other members of the healthcare team regarding documentation needed to support the patient's level of care.
Collaborate with Case Management and Social Services regarding discharge planning, transitions of care, and barriers to discharge.
Assist with payer authorizations, concurrent review submissions, and denial prevention activities as applicable.
Track and communicate authorization requirements and payer responses.
Identify potential denials and work proactively with providers and hospital staff to obtain appropriate clinical documentation.
Maintain accurate and timely utilization review records and documentation.
Participate in denial management, appeals, and retrospective review processes as assigned.
Monitor utilization trends and identify opportunities to improve resource utilization and patient flow.
Assist with education of physicians and staff regarding utilization management, documentation requirements, medical necessity, and payer expectations.
Maintain knowledge of current Medicare, Medicaid, commercial payer, and regulatory requirements applicable to utilization review.
Maintain patient confidentiality and comply with HIPAA and all applicable federal, state, and organizational requirements.
Perform other duties within the scope of RN licensure as assigned.

Benefits

Access to Employer Direct Care Clinic
Free medical care and pharmacy services for eligible employees and dependents covered by Wilson Health's medical insurance plan.
Generous paid time off (PTO) program beginning day one, designed to support work-life balance, rest, and time with family.
Medical Insurance: Choose from two High - Deductible Health Plan (HDHP) options or a PPO plan, along with Dental and Vision coverage.
Benefits begin on the first of the month following your hire date.
HSA with employer contribution for eligible health plans; FSA for medical and dependent care expenses.
Company-paid Life Insurance and Long-Term Disability Insurance
Voluntary Accident, Critical Illness, and employee and dependent Life and AD&D Insurance.
Industry-leading retirement plan – employer contributions begin day one with no waiting period for participation.
Tuition Assistance Program
Free access to an on-site gym, available 24/7, making it easy to prioritize your health and wellness before or after your shift.