Utilization Review Nurse

Silver Cross Hospital is an extraordinary place to work. We're known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serveand for each other. Come join us! It's the way you want to be treated.

Position Summary: Performs medical record review for severity of illness and intensity of service; liaison function with external review agencies to ensure compliance with regulations affecting financial reimbursement; identifies variance from established pathways

Essential Duties and Responsibilities:

• Collects information from clinical medical record for severity of illness and intensity of service and documents such in clinical database
• Monitors all levels of care for appropriateness and communicates variance; evaluates plan of care to ensure it is based on accepted standards
• Provides information to external review organizations, documents pertinent communications
• Refers to designated physician advisor those patients not meeting criteria as well as quality of care concerns
• Maintains knowledge and incorporates current standards into practice

Required Qualifications: Knowledge of clinical norms; excellent communication skills; critical thinking skills; organized and efficient time management skills

Education and Training:

• Nurse, Registered (RN) licensure
• BSN preferred. 2-5 years previous Utilization Review experience preferred.
• Current CPR
• Relevant hospital nursing; hospital case management; insurance case management or utilization management experience preferred

Work Shift Details:

Days, Primarily remote; onsite orientation requirement; weekend and holiday rotation; on site requirement for meetings and mandatory training

Department:

CONTINUUM OF CARE