Utilization Review Nurse Job Description Template
Our company is looking for a Utilization Review Nurse to join our team.
Responsibilities:
- Maintain thorough records of all patient related interactions;
- Attends required departmental, hospital and system meetings;
- Manage hospital database entering accurate, up-to-date information;
- Maintains knowledge of and is compliant with current UM Plan and policies & procedures;
- Prepare and maintain accurate quality data on all utilization management activities;
- Performs other duties as assigned.
Requirements:
- Experience handling authorizations;
- Familiarity with insurances;
- Familiarity with DME a plus;
- Understanding of healthcare reimbursement mechanisms preferred;
- Must be a Licensed Practical Nurse (LPN) OR a Registered Nurse (RN);
- Demonstrated adaptability to changes in health care environment with proactive problem solving attitudes;
- Understanding of the principles of performance improvement, team collaboration, and conflict resolution;
- Strong oral and written communication skills;
- Reviews level of care assignment to ensure compliance with government and regulatory standards including but not limited to the CMS 2-Midnight rule;
- Clinical expertise to discern and provide accurate,
- Refers denials for second level physician peer to peer medical necessity review;
- Knowledge of insurance web portals and management of insurance authorization status;
- Employ effective use of knowledge, critical thinking, and skills to advocate decreased hospital stay when appropriate;
- Concurrently monitors resource utilization, performs continued stay reviews and assists with managing the length of stay across the continuum;
- Keeps case management team informed of level of care and continued stay medical necessity.