RN Utilization Review

POSITION SUMMARY

Assume primary responsibility of cases for documentation of appropriate medical necessity for the third-party payer's inpatient and/or observation status. Communications with physician, ancillary staff, and payers and assists third party payers with clinical information for approval of stay and payment. Assists Director in appeals of stay that are denied, sets up physician to physician denials. Assures proper level of care assignment. Facilites with Case Managers and other allied health professionals to promote and ensure that quality care is provided and outcomes are achieved in a timely and cost-effective manner. Supports hospital goals and objectives in compliance with regulatory guidelines. Works in collaboration with all healthcare disciplines to assure a continuum of appropriate and timely services. Assess appropriateness, quality, and cost effectiveness of proposed hospital, medical and corporate goals and objectives.

EDUCATION AND EXPERIENCE

• Must be a graduate of an accredited school of Nursing, LPN preferred.
• Prefer a minimum of four years' experience in hospital setting.
• One-year experience in utilization management/case management is preferred.
• Must have skills in effective communication and critical thinking, ability to establish priorities, and creative problem solving.
• Must be able to work independently.
• License, if applicable, must be kept current.

Please indicate whether you have ever been convicted of a crime, including any misdemeanors and/or DUI/DWI. (Criminal conviction(s) will not automatically exclude you from consideration for employment).