JOB SUMMARY

The Utilization Review (UR) Nurse is a registered nurse who provides clinical review against nationally recognized medical necessity criteria for the purpose of evaluating medical necessity or hospitalization (inpatient and outpatient observation patients) regardless of payer type. The UR RN provides ongoing communication with health plan utilization departments regarding medical necessity for prospective, concurrent and retrospective reviews. The UR RN provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. The UR RN communicates with the Lead UR RN when potential medical necessity denials are determined by the payer. Both the UR RN and the Lead UR RN partner with physicians related to medical necessity appropriateness of admission and prevention of denials.

JOB REQUIREMENTS

Minimum Education Associates degree in Nursing required. Minimum Work Experience One (1) year recent Utilization Review (UR) experience in an acute care/hospital setting OR One (1) year recent experience as a Case Manager in an acute care/hospital setting OR Three (3) years of RN experience in an acute care hospital setting working with physicians and various levels of personnel such as a Nurse Manager position. Required Licenses/Certifications Registered Nurse  Certification through Commission for Case Manager (CCM) or American Case Management Association (ACMA) within 2 years of hire. Required Skills, Knowledge, and Abilities Ability to analyze documentation of clinical care from the medical record. Ability to demonstrate written and verbal communication skills to request and communicate clinical information. Ability to show critical thinking and analytic skills to review and apply medical necessity criteria. Demonstrates knowledge and effective use of various applications/systems/resources (Knowledge of Microsoft Outlook and Office (Word, Excel) and (Proficient in Allscripts EMR, Allscripts CM software program, IDX and 3M within 6 months). Ability to show strong commitment to interdisciplinary collaboration and communication. Ability to demonstrate strong computer skills. Ability to demonstrate excellent human relations skills. Ability to show creative problem solving. Ability to be proficient with organization and planning. Ability to show initiative and work with no supervision. Ability to efficiently manage time.