Utilization Review

RN Utilization Review

Elliot Health System's Care Coordination Department, located in Manchester, NH, plays a vital role in ensuring seamless, patient-centered care across the healthcare continuum. Our team is dedicated to care management, discharge planning, and patient advocacy, working closely with providers, social workers, and community resources to enhance patient outcomes. By developing individualized care plans, facilitating smooth transitions between care settings, and offering proactive support, we help patients navigate complex healthcare needs while improving overall access to high-quality, coordinated care.

Under the direction of the Director of Care Coordination, the Utilization Review RN (UR RN) is responsible for ensuring the effective and efficient use of hospital services in alignment with the hospital's utilization review plan.

What You'll Do:

• Complete admission reviews to determine the appropriate level of care.
• Document continued stay reviews to assess the necessity of inpatient care, procedures, and estimated length of stay.
• Communicate and collaborate with payer care managers to prevent denials by ensuring timely clinical reviews.
• Address potential denials proactively, working with physicians and payer representatives to minimize retrospective denials.
• Screen all patients upon admission or the next business day to determine appropriate level of care using medical necessity tools, Medicare Inpatient Only List, and payer requirements.
• Monitor observation status patients to ensure appropriate utilization, and collaborate with admitting physicians if documentation does not support the current level of care.
• Perform concurrent reviews to justify extended stays, working with attending physicians to ensure accurate documentation of medical necessity.
• Refer cases that do not meet admission or continued stay guidelines to the Utilization Review Physician Advisor after discussions with attending physicians.

Who You Are:

• Graduate of an accredited nursing program (Bachelor's degree in Nursing required for nurses hired after May 2015 or commitment to obtain within a specified timeframe).
• Minimum of three (3) years of experience in hospital case management or utilization management.
• Active New Hampshire or Compact State RN license required.
• CCM or ACM certification preferred.

Why You'll Love Us:

• Health, dental, prescription, and vision coverage for full-time & part-time employees
• Short-term, long-term disability, life & pet insurance
• Tuition reimbursement
• 403(b) Retirement savings plans
• Continuous earned time accrual