Registered Nurse - Utilization Review

1st TIME OK/ 2 YR EXP required for Utilization Review RN every other weekend required or more depending on unit needs no call or floating required MUST HAVE experience with Milliman Care Guidelines and Acute Hospital Experience!! The Emergency Prospective Review (EPR) Nurse - RN has the responsibility to conduct a review of all patients requiring hospital admission from the emergency room at all PIH and non-PIH facilities (for PHP members) after stabilizing care has been initiated for medical necessity and appropriateness. Also, the EPR-RN is responsible for reviewing all interfacility transfer request from non-PIH facility in accordance to transfer policies, Health and Safety Codes, and applicable laws (COBRA/EMTALA). The EPR-RN performs, and supervises the EPRN-LVN, in utilization review with a prominent level of expertise by using approved criteria that demonstrates medical necessity to achieve appropriate authorization and reimbursement for services for the appropriate level of care and status (Inpatient, Observation, or Outpatient). Certs: CA RN license Skills: Acute Hospital Emergency Department ICU Admission Criteria Benefits Eligibility Care coordination Concurrent Review Data Abstraction Determine Medical Necessity per Evidence-Based Guidelines Discharge Planning Needs Assessment/ Order DME Pre-Cert Review Prior Authorizations Utilize Milliman Guidelines CMS: Centers for Medicare and Medicaid Services CPT (Current Procedural Terminology) coding and billing DRG (Diagnosis Related Groups) HIPAA guidelines (Health Insurance Portability and Accountability Act) ICD 10 Coding OSHA The Joint Commission/ Core Measure/National Safety Goals Hard Stop hospital experience Excel prefer business casual RTO MUST BE SUBMITTED UP FRONT!