RN-Utilization Review Job Description
RN-Utilization Review Duties & Responsibilities
To write an effective rn-utilization review job description, begin by listing detailed duties, responsibilities and expectations. We have included rn-utilization review job description templates that you can modify and use.
Sample responsibilities for this position include:
RN-Utilization Review Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for RN-Utilization Review
List any licenses or certifications required by the position: CCM, ACM, BLS, OASIS, ICD, CPR, LPN, RN, TCM, CM
Education for RN-Utilization Review
Typically a job would require a certain level of education.
Employers hiring for the rn-utilization review job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Health, Graduate, Management, Healthcare, School of Nursing, Associates, Science, Nursing Program
Skills for RN-Utilization Review
Desired skills for rn-utilization review include:
Desired experience for rn-utilization review includes:
RN-Utilization Review Examples
RN-Utilization Review Job Description
- Assuring case mix index, Diagnostic Related Group (DRG) assignment and severity/mortality profiles are accurate by reviewing up-to-date reports
- Developing concurrent educational programs for physicians and other clinical staff to improve adherence to proper documentation
- Improve medical record physician documentation by performing concurrent medical record reviews and addressing incomplete documentation with direct interaction with Physicians
- Indirectly assuring case mix index, Diagnostic Related Group (DRG) assignment and severity/mortality profiles are accurate by reviewing up-to-date reports
- Meet required decision-making timeframes
- Clearly document all communication and decision-making within utilization review tracking platform
- Demonstrate the highest level of professionalism, accountability, and service
- Learn and use tools and processes to perform and properly track all utilization reviews
- Ensure information related to utilization management is received from hospitals, nursing facilities, medical providers and other health care entities
- Promote improved quality of care and/or life
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab strongly preferred
- Prevent hospitalization/readmission when possible and appropriate
- Prevent complications in patients by assuring discharge planning and transition of care continuity is in place and implemented for
- Collect relevant medical information and apply the appropriate evidence-based guidelines and medical policy
- Clearly document all communication and decision-making within our utilization review tracking platform
- Demonstrate the highest level of professionalism, accountability, and service in your interactions with teammates, customer service, providers, and members
RN-Utilization Review Job Description
- Acts as a liaison with the RN Care Coordinators and Care Coordination Social Workers to facilitate the appropriate utilization of hospital resources and timely discharge
- Reviewing, monitoring and documenting admission and continued stay reviews for all payors using Milliman Care Guidelines and the center’s Utilization Review Plan
- Working on admissions
- Obtaining determinations from insurance companies
- Making appeal recommendations
- Assist with discharge planning efforts
- Facilitating the continuum of care
- Timely discharge
- Provide clear and accurate information to insurance representatives, MD offices and Case Managers
- Promote and maintain collaborative working relationships
- Ability to adapt in a dynamic work envioronment while maintaining relationships with external staff members
- Demonstrated knowledge of diagnostic codes
- If selected for this role, a TB screen is required
- May act as an educational resource and provides consultation to hospital medical personnel regarding discharge planning process and applicable federal, state and local regulations
- Minimum 5 years of clinical nursing experience in an acute care hospital setting required
- Complete medical review and interpretation of medical record to obtain authorization of care and services
RN-Utilization Review Job Description
- Oversees the coordination and delivery of comprehensive, quality healthcare and services for all members requiring care management in a cost-effective manner
- Ensuring information related to utilization management is received from hospitals, nursing facilities, medical providers and other healthcare entities
- Promoting improved quality of care and/or life
- Preventing hospitalization / readmission when possible and appropriate
- Preventing complications in patients by assuring discharge planning and transition of care continuity is in place and implemented for
- Responsible for utilization review and discharge planning for capitated patients who are hospitalized
- The review includes coordination of services for medical necessity, cost effectiveness, timelines of service and ensuring that quality standards are met
- Performs coordination of services for patients whose health plan has an at-risk agreement to ensure that services are medically necessary, cost effective, provided in a timely manner and meet local standards or care
- Responsible for prospective, concurrent review and retrospective review authorizations and ongoing management for outpatient/inpatient medical, home health care and skilled nursing facilities
- Responsible for reviewing and making timely coverage recommendations based on medical appropriateness, for all products, while maintaining the integrity of each product line
- Utilization Review experience, or reviews for medical necessity, in a managed care, home health or hospital setting
- Ability to work in a dynamic environment while maintaining a consistent professional demeanor
- Active Compact RN license in MS
- Subject for travel based on client needs
- Knowledge of Milliman or Interqual criteria preferred
- Prior supervisory experience with direct reports
RN-Utilization Review Job Description
- Responsible for applying clinical skills and expertise in conjunction with established medical criteria, members’ eligibility and benefit coverage information, in the review of prior authorization requests, to ensure high quality, cost effective care
- Serves as subject matter expert on complex medical management issues for internal and external customers
- Pursues Physician Advisor services when treatment plan requests do not meet evidenced-based criteria
- Channels certified treatment plan requests to preferred vendors as necessary
- Maintains a score of 90% or higher on monthly internal utilization review audits
- Complete medical necessity review of charts
- Communicate with insurance companies when indicated to provide clinical reviews to obtain authorization for hospital stays
- Refer cases not meeting InterQual/Milliman criteria to Physician Advisor for evaluation and follow through with recommendations
- Consult with the physician whenever admission or continued stay does not meet approved criteria and cannot justify the admission or continuation of hospitalization
- Monitor and complete cases as identified on initial, concurrent and discharged review work queue
- One year of experience in Utilization Review preferred
- Weekend/Holiday Rotation Required
- Graduate of an accredited Registered Nursing Program, Bachelor Degree preferred
- Minimum of three years diverse clinical experience as RN
- Minimum of two years case management and/or utilization review experience
- Strong clinical practice knowledge
RN-Utilization Review Job Description
- Actively communicate with and assist Case Managers
- Support compliance with HFAP, State, and Federal Agencies for assigned areas
- Keep abreast of current trends in Utilization Review and Managed Care processes
- Maintain accurate, concise, and timely documentation in Epic
- Work collaboratively with the multiple disciplines, both internal and external to the organization, in effecting quality and cost-effective management of the patient care along the continuum
- Conduct pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts
- Facilitate member care transition through the healthcare continuum and refer treatment plans / plan of care to Clinical Reviewers as required and does not issue non-certifications
- Maintains a collaborative working relationship with the payor's utilization review nurses and case managers and maintains contact with the payor regarding initial assessment, progress, changes in condition, discharge planning, discharge date, as needed
- Demonstrates performance consisten with professional standards of practice, care, performance, the Nurse Practice Act
- Coordination of services for medical necessity, cost effectiveness, timelines of service and ensuring that quality standards are met
- CCM or Utilization Review/Management certification
- Working knowledge with INTERQUAL or Milliman
- Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers
- Basic proficiency with MS Office, Word and Excel
- Must have strong PC skills with current operating systems
- Must have outstanding telephonic and personable skills to communicate with various entities, ( ie