UTILIZATION REVIEW NURSE - RN

POSITION SUMMARY:

The Utilization Review Registered Nurse (UR RN) is a key contributor to the delivery of appropriate, efficient, and cost-effective patient care. Working collaboratively within a multidisciplinary team, the UR RN conducts comprehensive reviews of clinical documentation, assesses medical necessity, and coordinates with healthcare providers and payers to support optimal patient outcomes and resource management. This role demands a solid clinical nursing background, sharp analytical skills, and a thorough understanding of regulatory standards and payer guidelines.

JOB-SPECIFIC RESPONSIBILITIES:
• Service


o Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems

o Upholds the Standards of conduct and corporate compliance.

o Demonstrates honest behavior in all matters. To the best of the employee's knowledge and understanding, complies with all Federal and State laws and regulations.

o Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.

o Adheres to all Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)

o Collaborates effectively with colleagues and other departments to ensure seamless service delivery.

o Maintain the highest level of confidentiality and professionalism in all interactions.
• Excellence


o Conduct concurrent and retrospective reviews to assess the medical necessity of behavioral health services, ensuring compliance with payer specifications and organizational policies.

o Utilize evidence-based criteria (e.g., InterQual) to evaluate the appropriateness of care.

o Document utilization review activities accurately and timely within the electronic health record (EHR).

o Participate in weekly utilization review meetings to discuss cases, discharge plans, and barriers to discharge.

o Monitor key performance indicators (KPIs) and contribute to process improvement initiatives.

o Communicate effectively with all stakeholders across the health system.

o Demonstrate teamwork and collaboration to support a cohesive Utilization Review team.

o Provide coverage and support for team members as needed.
• Patient Experience and Advocacy


o Educate treatment teams on comprehensive documentation practices to reflect patient status and treatment plans accurately.

o Collaborate with case management to address discharge planning, expected length of stay (ELOS), and potential barriers.

o Advocate for patients by ensuring access to necessary services and facilitating transitions to appropriate levels of care.
• Quality Assurance and Compliance

o Ensure all activities adhere to healthcare regulations and organizational policies.

o Participate in quality improvement initiatives to enhance service delivery.

o Promotes a culture of patient safety which results in the identification and reduction of unsafe practices.

o Ensure adherence to applicable state and federal regulations, accreditation standards, and payer requirements.

o Participate in quality improvement, utilization management committees, and risk management activities.

o Perform ongoing quality assurance audits to evaluate the effectiveness of utilization review processes.

o Stay informed about changes in healthcare policies, regulations, and best practices related to utilization management.
• Professional Growth and Continuing Education

o Completes annual education requirements.

o Maintains competency, as evidenced by completion of competency validation requirements.

o Maintains competency and knowledge of current standards of practice, trends, and developments.

o Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices.

o Engage in continuing education opportunities to maintain clinical competencies and stay current with industry standards.

o Attend departmental meetings, in-services, and training sessions as required.

o Pursue relevant certifications to enhance professional development and expertise in utilization review.
• Finance

o Promotes stewardship of hospital resources while ensuring quality patient care.

o Manage denials and appeals processes, including evaluating root causes and developing strategies to minimize occurrences.

o Collaborate with internal departments to address unfunded days and work towards overturning denials.

o Facilitate authorization requests for level-of-care changes and insurance updates.

o Analyze utilization data to identify trends and opportunities for cost savings.
• Performs other duties as assigned.


POSITION QUALIFICATIONS:

EDUCATION:
• Associate Degree in Nursing (ADN) from an accredited institution required
• Bachelor of Science in Nursing (BSN) from an accredited institution preferred.

EXPERIENCE:
• Minimum of 2 years of clinical nursing experience in an acute care setting.
• At least 3 years of experience in utilization review, case management with complex medical/surgical and/or behavioral health cases.
• Experience with behavioral health services is advantageous.
• 2-3 years' experience with InterQual or MCG preferred.

SKILLS: (new section)
• Strong analytical and critical thinking abilities.
• Excellent written and verbal communication skills.
• In-depth knowledge of healthcare regulations, payer guidelines, and accreditation standards.
• Ability to work independently and collaboratively within a team environment.
• Effective time management and organizational skills.
• Strong computer skills with demonstrated proficiency in electronic health records (EHRs) and utilization management software systems. Preferred experience with Meditech and Microsoft Office applications, including Outlook, Teams, Excel, Word, and SharePoint.

LICENSURE/CERTIFICATION:
• Current and unrestricted Registered Nurse (RN) license in the State of Texas or compact license (required).
• Certification in Case Management (CCM), Healthcare Quality (CPHQ), or Utilization Review (e.g., HCQM) is preferred.
• Basic Life Support (BLS) certification as required for facility based staff; optional for remote staff.