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Job Summary:
The Utilization Review Nurse is responsible for following the healthcare system's Utilization Program which integrates the function of utilization review and resource management to assure care is provided in the most appropriate setting utilizing medically indicated resources. The Utilization Review model outlines a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes. The Utilization Review Nurse is responsible for ensuring services provided are compliant with professional standards, national and local coverage determinations, the Centers for Medicare and Medicaid Services (CMS) as well as state and federal regulatory requirements, as applicable.

Essential Functions and Responsibilities:

• Applies clinical criteria to monitor appropriateness of admissions and continued stay.
• Documents findings and relays information to primary physician as needed.
• Identifies and refers cases to physician advisor per UR policy as appropriate.
• Manages any denials related to information provided to/received from payers.
• Assures that key regulatory requirements are met.
• Documents key updates using appropriate software.
• Collects denial data for outcome and key performance indicators and documents accordingly.
• Identifies appropriate regulatory letters needing to be delivered to patients and families and communicates need to the Unit Care Team.
• Educates physicians and staff regarding appropriate level of care/utilization issues.
• Assures correct documentation of utilization review status within Electronic Health Record Utilization Review Module for timely claim filing.
• Manages and maintains EPIC Work ques related to Utilization Review and timely claim filing.
• Other duties as assigned.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.