What are the responsibilities and job description for the Utilization Review Nurse position at Mile Bluff Medical Center?
General Information:
Job title: Utilization Review Nurse
Schedule: Full-time, 80 hours per pay period
Weekend rotation: None required
Holiday rotation: None required
Position Summary:
The Utilization Review Nurse position plays a critical role in ensuring the appropriate use of healthcare resources while maintaining high-quality patient care. This position is responsible for conducting utilization reviews, assisting with resolving inpatient and OBS payment issues/denials, and providing administrative support to the Director of Quality.
Position Responsibilities:
- Obtain prior authorization and timely insurance notification.
- Communicate Provider plans to notify insurance entities.
- Evaluate, and intervene, if necessary, appropriateness of admission and placement using MCG Guidelines in conjunction with documentation in the patient's medical record
- Coordinate with Hospitalist and care manager to facilitate timely discharge of patients.
- Coordinate as appropriate with Denial and Appeals management, Case Manager, Patient Accounts and other necessary parties for denials, appeals, and medical necessity reviews
- Validates correct insurance information is on file. Works with registration to correct any incorrect information
- Provides financial information and resources to uninsured/underinsured patients
- Monitors for timely and accurate completion of regulatory forms that apply to role (MOON forms etc.)
- Identify, analyze, and interprets data from a variety of clinical and financial sources
- Prepare reports and information for Utilization Review meetings.
- Perform other duties as requested.
Position Requirements:
- Two-year degree in nursing required. Four-year degree in nursing preferred.
- Must hold and maintain nursing license. RNs with an active Compact Licensure are to obtain a Wisconsin RN license within 90 days of relocation.
- BLS within 6 months of hire.
- 1 years of related work experience required.
- Exceptional accuracy and attention to detail required.
Knowledge, Skills, & Abilities
- Physical strength and dexterity to operate necessary machinery and perform all required cleaning duties.
- Ability to read any special instructions and to understand labels on cleaning products.
- Self-starter with excellent interpersonal communication skills.
- Ability to have continuous oral and written communication with co-workers and supervisors is essential.
