Utilization Review Nurse

ABOUT SHERIDAN MEMORIAL HOSPITAL


At Sheridan Memorial Hospital, we proudly rank in the top 13.6% of U.S. hospitals, recognized by the Centers for Medicare and Medicaid Services. With over 850 dedicated employees and 100+ expert providers across 25 specialties, we are committed to exceptional, patient-centered care. Set in northern Wyoming's stunning Big Horn Mountain foothills, Sheridan offers outdoor adventure and community charm. Our hospital combines cutting-edge technology with a collaborative, innovative culture. Join a team that values your skills, fosters growth, and empowers you to impact lives meaningfully. Apply today and be part of Sheridan Memorial Hospital's mission of excellence!


JOB SUMMARY

The performance of the Utilization Review function on all patients presenting for hospitalization to assist in identifying patients appropriate for admission to inpatient, observation, or other patient care status. Conducting a continued stay review evaluating the medical necessity, appropriateness and efficient use of health care services for all hospitalizations, inpatient or outpatient. Collaborating with the physicians, health care team and care coordinator to optimally certify the level of care and facilitate the patient's movement throughout the continuum of care as appropriate.


Essential Job Functions

• Demonstrates expertise in the application of MCG and InterQual criteria.
• Reviews all requests for changes in status for admission from the Inpatient Units, PACU, cardiac catheterization area, or any outpatient surgery areas. Applies MCG and InterQual criteria to determine appropriateness for level of care requested, consulting with the attending physician as necessary.
• Insures operative procedure performed is the operative procedure prior-authorized by the third-party payor and communicates any variance.
• Identification of high risk social issues and referral to the Social Worker, Manager or Director as appropriate.
• Proficiency with use of Conditional Code 44 and Code W2.
• Monitors the use of healthcare resources. Communicates with physicians to assure the patient receives diagnostics/evaluations in the proper setting, i.e. inpatient vs outpatient.
• Maintains current knowledge of CMS (Medicare) rules and regulations.
• Communicates openly with third party payors and works collaboratively with them to avoid concurrent denials.
• Sends clinicals to third party payors when warranted or requested.
• Collaborates with the care coordinator to ensure an appropriate level of care.
• Actively participates in the Case Management Huddle.
• Identifies and documents delays in service as avoidable days.
• Serves as an expert resource to physicians and healthcare staff in the application of MCG and InterQual criteria and the use of evidence-based practices.
• Conducts initial (admission) reviews at the time of presentation, or within 24 business hours, if patient presents during uncovered hours.
• Conducts concurrent review per department policy (every 2 days for inpatient status unless the patient's condition changes), and as private payor dictates.
• Conducts observation and outpatient reviews daily.
• Follows department policy regarding escalation of utilization issues to the Physician Advisor or his/her designee.
• Participates in the Utilization Review Committee.
• Completes Extended Stay reviews at 10 and 20 days.
• Processes denials and appeals in a timely manner.

POSITION QUALIFICATIONS -Education, Experience & License

• Current unrestricted Wyoming Registered Nurse License.
• Bachelor's Degree in Nursing or related field with case management experience, preferred.
• BLS, required.
• 3-5 years of recent hospital-based patient care or relevant experience.
• 3-5 years Milliman or InterQual experience, preferred.
• HMO, managed care, PPO, Utilization Management/medical management experience preferred.

Additional Skills

• Knowledge and understanding of process improvement, theory/tools.
• Knowledge and understanding of TJC standards. Understanding of CMS and all other regulatory requirements.
• Knowledge of performance improvement principles, tools and techniques
• Ability to take initiative and work with minimum supervision
• Must be proficient in the use of Microsoft Office applications, including Excel, Word, PowerPoint and Outlook.
• Must possess sound oral and written communication skills, including clear articulation of ideas, proper grammar and spelling, and poise and professional appearance.
• Attention to detail with follow-up is necessary.

Specific demands not listed: Possible exposure to blood and or body fluids / infectious disease / hazardous waste requiring the use of Personal Protective Equipment. Exposure to odorous chemicals / specimens and Latex products. Pre-employment drug and alcohol screening is required.


Sheridan Memorial Hospital is an equal opportunity/Affirmative Action employer and gives consideration for employment to qualified applicants without regard to race, color, religion, age, sex, national origin, disability or protected veteran status. If you would like more information about your EEO rights as an applicant under the law, please click here.