Job Summary:

We are seeking a Part-Time Utilization Review Nurse to join our dedicated healthcare team. In this role, you will play a critical part in ensuring that patients receive appropriate and effective medical care while adhering to established clinical guidelines and healthcare policies. Your expertise will be instrumental in assessing the necessity, appropriateness, and efficiency of healthcare services, and collaborating with healthcare providers to optimize patient outcomes.

Physical Requirements:

While performing the duties of this job, the employee is regularly required to sit, talk, and hear.  The employee is frequently required to use fine motor skill (typing/data entry) and reach with hands and arms. The employee is frequently required to stand; walk; and occasionally stoop, kneel, or crawl.  The employee must regularly lift and /or move up to 20 pounds and occasionally lift and/or move up to 50 pounds.

OSHA Exposure Classification:

Job Classification I.  Direct contact with blood or other body fluids to which universal precautions apply. Personal protective equipment is made available and must be worn.

Qualifications, Knowledge & Ability:

• Current Registered Nurse (RN) license in the state of practice
• Experience in utilization review, acute hospital case management, or quality assurance
• 2 years of clinical nursing experience in a hospital or healthcare setting
• Strong understanding of medical terminology, clinical guidelines, and utilization review processes
• Proficient in data analysis and interpretation, with the ability to make informed decisions based on clinical evidence
• Excellent communication and interpersonal skills, with a focus on collaboration and patient advocacy
• Preferred experience with MCG Indicia

Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem-solving skills and computer literacy.

Duties and Responsibilities:

• Conduct comprehensive reviews of patient medical records and treatment plans to assess the necessity and appropriateness of care provided.
• Utilize clinical knowledge to interpret medical documentation and determine compliance with established guidelines and criteria.

• Collaborate with healthcare providers to discuss treatment options, address concerns, and facilitate effective communication regarding patient care.
• Document findings and decisions accurately, ensuring compliance with regulatory requirements and organizational policies.
• Participate in interdisciplinary team meetings to provide insights on utilization trends and recommend improvements to care delivery.
• Educate patients and providers on utilization review processes and criteria to promote understanding and adherence.
• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Assures the patient is in the appropriate status and level of care based on Medical Necessity
• Ensures timely communication of clinical data to payers to support admission, level of care, length of stay and authorization
• Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
• Identifies and documents Avoidable Days using the data to address opportunities for improvement
• Prevents denials and disputes by communicating with payers and documenting relevant information
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.

COMPETENCIES:

• Accuracy – Ability to perform work accurately and thoroughly.
• Communication – Ability to communicate effectively verbally and in writing.
• Computer Skills – Proficient ability to use a computer and electronic medical record.
• Confidentiality – Maintain patient, team member and employer confidentiality.
• Comply with all HIPAA regulations.