What are the responsibilities and job description for the Utilization Review Nurse position at St. Claire HealthCare?
The Utilization Review Nurse role supports managing a utilization review program through planning, data analysis, and goal setting to ensure entitled reimbursement and compliance with guidelines.
Duties/Responsibilities
Associate’s Degree in Nursing (ADN) required; Bachelor’s Degree in Nursing (BSN) preferred
Experience
Five years of experience as a Registered Nurse in acute care required; Case Management/Utilization Review experience preferred
Licensure/Certification
Valid Kentucky Board of Nursing (KBN) license
PI266487544
Duties/Responsibilities
- Actively supports utilization review services to obtain authorization for payment from 3rd party payers in preadmission, admission, continued stay areas, and outpatient certification.
- Establishes and maintains payer contact and referral information for timely escalation of issues.
- Assists with ongoing updates/maintenance of the UR Guide with payer-specific contacts and requirements. Shares information/educates team members to ensure the integrity of UR services when others provide coverage.
- Evaluates the appropriateness of treatment and severity of illness using criteria approved by the Medicare Peer Review Organization. Assists with arranging peer-to-peer reviews as necessary.
- Identifies, escalates, and works to resolve system problems, barriers, and delays that impede the plan of care, discharge, or reimbursement; Initiates recommendations/options rather than wait for a referral.
- Communicates effectively to improve quality, safety, satisfaction, and effective discharge planning. Seeks methods to streamline information sharing effectively.
- Refers cases to Case Management Physician Advisor and takes appropriate action when cases fail criteria.
- Collaborates and communicates with the Patient Access Department and Business Office on individual cases to ensure an effective revenue cycle.
- Completes retrospective reviews from all payers through timely and effective interventions.
- Maintains accurate and up-to-date medical records and documentation timely.
- Provides evaluation, recommendations, and/or referrals for performance improvement, patient safety, and risk.
Associate’s Degree in Nursing (ADN) required; Bachelor’s Degree in Nursing (BSN) preferred
Experience
Five years of experience as a Registered Nurse in acute care required; Case Management/Utilization Review experience preferred
Licensure/Certification
Valid Kentucky Board of Nursing (KBN) license
PI266487544
