Utilization Review Registered Nurse

Monument Health•Rapid City, SD

20h

About The Position

Responsible for review and completion of denial/appeal requests. Stays current with Federal and State regulations regarding medical necessity for inpatient and observation hospitalizations. Will collaborate with Case Managers, Utilization Review Medical Directors, Corporate Compliance, Admissions and Patient Financial Services on patient status for accuracy of billing. Responsible for utilization review duties in collaboration with Case Managers. Completes audits for appropriate utilization of resources, develops/implements action plans when appropriate. Establishes goals and priorities consistent with mission and goals of Monument Health, as well as meets requirements of Joint Commission and other applicable federal, state and local regulatory and/or accrediting bodies. Monument Health offers competitive wages and benefits on qualifying positions. Some of those benefits can include: Supportive work culture Medical, Vision and Dental Coverage Retirement Plans, Health Savings Account, and Flexible Spending Account Instant pay is available for qualifying positions Paid Time Off Accrual Bank Opportunities for growth and advancement Tuition assistance/reimbursement Excellent pay differentials on qualifying positions Flexible scheduling

Requirements

Education - Completion of a nursing education program that is approved by a board of nursing
Certification - Registered Nurse (RN) - South Dakota Board of Nursing

Nice To Haves

Education - Bachelors in Nursing
Work Experience - 3+ years of Registered Nurse experience, 1+ year Utilization Review experience.

Responsibilities

Advocates for payment of services, collaborates with physicians and the UR Committee.
Facilitates the completion of medical necessity reviews for hospitalized patients and discharged medical record review as needed for appropriate patient status / service and plan of care.
Assists in timely completion of denial reviews and assists to identify any trends.
Promotes the optimal allocation of health dollars through accurate, effective and timely appeals.
Stays current with the provider aspect of federal/state organization regulations related to inpatient and observation hospital level of care.
Supports compliance with Utilization Review and regulatory guidelines.
Identify trends related to compliance of regulations and collaborates with appropriate hospital personnel and external agencies to ensure appropriate process changes are implemented.
Applies up-to-date information related to reimbursement procedures, managed care contracts.
Fosters and role models an atmosphere of interdisciplinary collaboration and communication across the system and with both internal and external entities and disciplines.
Elevates appropriate cases to leadership for review.
Any other duties as assigned.