Utilization Review Nurse (Full-Time/ Day Shift)

Job Description

Job Description

Description:

The Utilization Review Nurse is responsible for conducting admission and continued stay reviews to ensure appropriate utilization of hospital resources and compliance with medical necessity criteria, payer requirements, regulatory standards, and organizational policies. The Utilization Review Nurse works collaboratively with physicians, case managers, revenue cycle staff, and interdisciplinary care teams to facilitate appropriate patient status determinations and optimize reimbursement while supporting quality patient care. This position requires extensive acute care nursing experience and demonstrated expertise in utilization review within a hospital setting.  8, 10 or 12 hour shift options. 

• Perform hospital admission reviews to determine medical necessity and appropriate patient status (inpatient, observation, outpatient). 
• Conduct continued stay reviews using approved clinical criteria and guidelines. 
• Evaluate clinical documentation for accuracy, completeness, and compliance with payer and regulatory requirements. 
• Apply evidence-based criteria such as InterQual® and/or MCG®. 
• Communicate review findings and recommendations to physicians, case management staff, and leadership. 
• Collaborate with Physician Advisors regarding complex cases or cases not supported by criteria. 
• Assist with denial prevention activities and accurate documentation. 
• Performs other duties as assigned. 
• Proficient in multiple Electronic Health Records and case management systems 
• Strong communication skills. Communicates clearly and concisely, verbally and in writing 
• Ability to thrive in a fast-paced environment and adapt to frequent changing business needs 
• Ability to work independently, needing minimal supervision. 
• Graduate of an accredited school of nursing 
• Bachelor’s of Science in Nursing (BSN): preferred 
• Current, unrestricted Registered Nurse (RN) license. 
• Minimum five (5) years of acute care nursing experience in a hospital setting 
• Minimum two (2) years of recent hospital-based utilization review experience 
• Experience with acute admission reviews and continued stay reviews 
• Certified Case Manager (CCM), Accredited Case Manager (ACM), or Certified Managed Care Nurse (CMCN), or Case Management Board Certification (CMGT-BC): preferred. 
• Full-time employees may be scheduled for 8-, 10-, or 12-hour shifts based on operational needs and mutual scheduling agreements. 
• Employees are expected to work every other weekend as required to support business operations. 
• Three (3) of the six (6) company-recognized holidays will be assigned annually based on departmental and business needs. 
• Work schedules are published one month in advance. Requests for vacation, time off, or schedule accommodations must be submitted at least thirty (30) days before the schedule is finalized (e.g., requests for the August schedule must be submitted by June 30). 
• Conditions typically associated with an office environment.  While performing the essential duties and responsibilities, the employee is regularly required to speak or hear.  May be frequently required to sit, stand or walk.  Moderate to prolonged reading, typing, and computer work.  Ability to perform tasks involving physical activity that may include lifting up to 25 pounds.  Subject to exposure to all environmental hazards associated with healthcare and office work.