Utilization Review Nurse Job Description

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.