St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Utilization Review Nurse will be responsible for substantiating medical necessity and clinical appropriateness of services in order to achieve quality outcomes and ensure appropriate reimbursement. JOB DUTIES AND RESPONSIBILITIES: Screens selected medical records in accordance with contractual agreements and departmental policies for appropriateness of admission; performing initial, continued stay, and retrospective reviews if applicable. Submits initial reviews and updates using established criteria and communicates with payers as appropriate, using established processes. Utilize established processes with the Physician Advisors to manage second level and peer to peer reviews. Ensure patient status and levels of care are appropriate on admission and prior to discharge. Makes timely contact with payers and provides information as appropriate. Documents all utilization review outcomes and activities appropriately in the medical record. Complies with all applicable payer, state and federal regulations as well as The Joint Commission requirements regarding Care Management and Utilization Review processes. Acts as resource for and provides updates to the care management staff and care team for issues related to utilization review processes. Engages providers with concerns regarding medical necessity and appropriateness of services. Escalate concerns related to medical necessity and appropriateness of services to the Physician Advisors. Works collaboratively with the Denials Specialist and Physician Advisors to manage retrospective appeals and documents according to established policy. Works collaboratively with the business office/finance to ensure proper reimbursement. PHYSICAL AND SENSORY REQUIREMENTS: Sitting for one to two hours at a time. Standing for up to 2 hours per day, up to 10 minutes at a time. Walk on all surfaces for up to 3 hours per day, and climb stairs. Must be capable of driving a car. Fingering and handling objects frequently, uses fingers to turn pages. Frequently uses hands to write and/or type. Rarely uses hands or fingers for firm grasping or twisting/turning. Frequently uses upper extremities to lift and carry object up to 10 lbs. Rarely may be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Must have the ability to hear as it relates to normal conversations and high and low frequencies and to see as it relates to general and peripheral vision. Must have the ability to touch as related to telephone and computer keyboard. EDUCATION: Graduate of professional nursing program. Registered Nurse with current license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity. NJ RN licensure required upon hire. Advanced degree preferred. TRAINING AND EXPERIENCE: At least 3 years of clinical experience as a registered nurse in an acute setting. Either 2 years of hospital or payor based utilization review experience preferred. Knowledge of Interqual and Milliman criteria preferred. Care Management certification preferred. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer. Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 20,000 employees providing services at 15 campuses and 300 outpatient sites. With annual net revenue of $3.5 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Fortune/Merative 11 times total and eight years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. SLUHN has been named a Top Workplaces 2023 by the Morning Call. In addition, St. Luke’s has been named a Top Workplace nationally, in the Philadelphia region, and in New Jersey. St. Luke’s is the ONLY healthcare institution in Pennsylvania and the third-highest ranked healthcare entity in the nation to be deemed a Top Workplace in 2023. In 2023, St. Luke’s was named one of America’s Best Employers for Women by Forbes. St. Luke’s was the only employer in the Lehigh Valley to be named to the list and was one of only two healthcare employers in Pennsylvania to receive the designation. St. Luke’s University Health Network is the top-ranked Lehigh Valley-based employer in Forbes Magazine’s ranking of employers in Pennsylvania. Learn More Here.