Utilization Review Registered Nurse (UR RN)

ProviDRs Care•Wichita, KS

6d•Onsite

About The Position

The Utilization Review Registered Nurse (UR RN) performs clinical utilization review for health plans administered by the Third-Party Administrator. The role evaluates requests for healthcare services against medical-necessity and utilization-management criteria, health-plan provisions, organizational policies, and regulatory requirements. Reviews may be prospective, concurrent, or retrospective and use approved evidence-based criteria, plan documents, clinical policies, and available medical documentation. The UR RN collaborates with healthcare providers, facilities, the Medical Director, Case Management, Care Navigation, Claims, pharmacy benefit managers and specialty pharmacies, stop-loss resources, provider networks, and other stakeholders. Within delegated authority, the nurse may approve services that meet established criteria. Cases that do not meet criteria, involve clinical uncertainty, or may result in an adverse medical-necessity determination are referred to the Medical Director or another appropriately qualified physician reviewer. This is a staff-level, non-exempt, full-time hourly position requiring on-site work in Wichita, Kansas. The position is eligible for overtime compensation under applicable law. Occasional overtime may be necessary because of time-sensitive or urgent review requests, and all hours worked must be accurately recorded.

Requirements

Current, unrestricted Registered Nurse (RN) license.
Graduate of an accredited nursing program.
Strong clinical assessment and critical-thinking skills.
Ability to interpret medical records and clinical documentation.
Knowledge of medical terminology, diagnoses, procedures, medications, and levels of care.
Strong written and verbal communication skills.
Strong organizational skills.

Nice To Haves

Minimum of three years of clinical nursing experience (preferred).

Responsibilities

Perform prospective, concurrent, and retrospective utilization reviews for inpatient and outpatient services, procedures, therapies, diagnostic testing, durable medical equipment, specialty medications, and other services subject to review or prior authorization.
Review medical records and clinical documentation; apply approved evidence-based criteria; assess medical necessity, level of care, site of service, frequency, and duration; and document clinical rationale.
Approve services that meet applicable criteria within delegated nursing authority and refer cases requiring physician judgment or potentially adverse determinations to the Medical Director or another qualified physician reviewer.
Request missing clinical documentation and complete reviews within applicable regulatory, contractual, plan-specific, and departmental timeframes.
Conduct prospective and urgent reviews, evaluate requests for routine or expedited processing, and identify clinically appropriate alternative sites of care when applicable.
Conduct concurrent reviews of inpatient admissions and ongoing services; obtain clinical updates; assess continued medical necessity, treatment progression, length of stay, discharge planning, and barriers to discharge; and identify appropriate transitions to lower levels of care.
Refer members with complex discharge needs, significant medical conditions, or ongoing coordination needs to Case Management or Care Navigation, and escalate potential reductions or terminations of authorized services as required.
Conduct retrospective reviews when appropriate, applying relevant criteria and plan provisions to the clinical information available when services were rendered.
Prepare cases for Medical Director review, coordinate peer-to-peer discussions when appropriate, document decisions and outcomes, process resulting authorizations, and initiate required notifications.
Assist with utilization-management appeals by gathering records and supporting materials, routing appeals to qualified reviewers, monitoring timelines, documenting outcomes, and processing modified or overturned determinations.
Review plan documents and benefit provisions to identify prior-authorization requirements, exclusions, limitations, and coverage concerns; distinguish medical-necessity review from benefit determinations and escalate unclear plan language.
Review specialty-medication requests when assigned; identify benefit and plan requirements; coordinate with PBMs, specialty pharmacies, Case Management, and other resources; and escalate complex sourcing or coverage questions.
Identify potentially high-cost or catastrophic cases and follow procedures for notifying Case Management and leadership and supporting stop-loss reporting, while keeping financial considerations separate from clinical medical-necessity decisions.
Identify members who may benefit from Case Management or Care Navigation referrals and communicate relevant information to support continuity and coordination of care.
Maintain accurate, complete, objective, timely documentation and audit trails for clinical information, criteria, communications, determinations, physician reviews, peer-to-peer discussions, and notifications.
Communicate professionally with providers, facilities, members and authorized representatives, physician reviewers, internal departments, PBMs, specialty pharmacies, provider networks, stop-loss resources, and leadership.
Follow applicable federal and state requirements, HIPAA and privacy policies, plan requirements, and organizational procedures for reviews, adverse determinations, appeals, expedited reviews, peer-to-peer review, and notifications.
Participate in utilization-management audits and quality reviews and complete required compliance, privacy, clinical, and utilization-management education.
Meet applicable productivity, turnaround-time, documentation, accuracy, communication, escalation, referral, and compliance expectations.
Accurately record all hours worked, work only during scheduled or authorized hours, seek advance overtime approval when practicable, report all overtime, avoid off-the-clock work, and notify a supervisor when workload may require overtime.