Utilization Review Nurse- Pool

Dayton Children's Hospital

3d

About The Position

Under the supervision of the Manager of Utilization Management, the Utilization Review RN conducts medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, Joint Commission, CMS, and other agencies. Prospectively, concurrently, or retrospectively determines the appropriateness of inpatient, observation, and extended recovery services following review of relevant medical documentation and medical guidelines and communicates information to payers in accordance with contractual obligations. The Utilization Review RN serves as a resource to the physicians, collaborates with the Care Manager in the development and implementation of the plan of care, and collaborates with the Denials team assisting to prevent concurrent and retrospective denials. The Physician Advisor role will support the Utilization Review RN for second level clinical reviews for cases that do not meet medical criteria, complex cases, appropriate level of care, Medicare cases as required, and the need for Peer-to-Peer reviews. Collaboration with Physician Advisor will support policy development, process improvement, and staff education related to clinical denial mitigation. At Dayton Children's, we believe that each moment counts with our patients, families, and with each other. We are moving at a fast pace and are looking for the right talent for our team at Dayton Children's. We want people who embody our values and want to become a part of the Dayton Children's difference. If this is you, apply today! Our values: We commit to safety - We ensure every action and decision prioritizes the safety of patients, families, and employees. We serve with compassion - We bring generosity, empathy, and kindness to all interactions. We own every moment - We take pride in everything we do. We’re better together - We collaborate, communicate, and support one another to deliver optimal care. We innovate with purpose - We adapt and change to improve pediatric care, for today and tomorrow. We value and respect each person - We create an inclusive space where everyone feels welcome and respected. Dayton Children’s is proud to be an Equal Opportunity Employer that values diversity and will not discriminate against minorities, women, protected veterans, individuals with disabilities, or based on age, color, gender identity, national origin, race, religion, sex, sexual orientation, or transgender status.

Requirements

• Completion of accredited RN program with current RN license in Ohio required
• Graduate of an accredited BSN Nursing Program required
• Two years’ experience required in the acute care setting, preferably in pediatrics.
• Current knowledge of reimbursement requirements, level of care criteria, APR-DRGs, MCG guidelines
• Exceptional oral and written communication skills
• [Lic] RN: Registered Nurse (RN) - Ohio Board of Nursing

Nice To Haves

• Proficiency in Microsoft Word, Excel, PowerPoint and Epic Systems preferred

Responsibilities

• Conducts medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, Joint Commission, CMS, and other agencies.
• Prospectively, concurrently, or retrospectively determines the appropriateness of inpatient, observation, and extended recovery services following review of relevant medical documentation and medical guidelines and communicates information to payers in accordance with contractual obligations.
• Serves as a resource to the physicians
• Collaborates with the Care Manager in the development and implementation of the plan of care
• Collaborates with the Denials team assisting to prevent concurrent and retrospective denials.
• The Physician Advisor role will support the Utilization Review RN for second level clinical reviews for cases that do not meet medical criteria, complex cases, appropriate level of care, Medicare cases as required, and the need for Peer-to-Peer reviews.
• Collaboration with Physician Advisor will support policy development, process improvement, and staff education related to clinical denial mitigation.

What This Job Offers

• Job Type: Part-time
• Number of Employees: 1,001-5,000 employees