Utilization Review Nurse Job Description
Utilization review nurse
provides decision support to the admitting office, registration and nursing supervisor as well as physicians’ office staff regarding appropriateness of admission, Interqual, denials, and insurance issues.
Utilization Review Nurse Duties & Responsibilities
To write an effective utilization review nurse job description, begin by listing detailed duties, responsibilities and expectations. We have included utilization review nurse job description templates that you can modify and use.
Sample responsibilities for this position include:
Review and evaluate all requests for elective inpatient admissions
Review and evaluate all requests for services requiring pre-authorization
Authorize inpatient and pre-authorization requests based upon evidence based UM criteria, coverage guidelines and benefit structure
Manage the daily inpatient census
Conduct initial inpatient review and determine appropriateness of admission, anticipated length of stay and potential discharge needs
Prioritize concurrent review of members
Accept telephone and faxed clinical information and capture information in the member record in accordance with acceptable standards for documentation
Assess and coordinate transitions of care settings including facility to facility and facility to home
Generate organization determination notices in compliance with all regulatory standards for specific product line
Expeditiously refer cases not meeting clinical guidelines/criteria to CMO for review
Utilization Review Nurse Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Utilization Review Nurse
List any licenses or certifications required by the position: BLS, ABQAURP, CPR, AHA, GOLD, MCG, CCM, AED, UR, PRI
Education for Utilization Review Nurse
Typically a job would require a certain level of education.
Employers hiring for the utilization review nurse job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Graduate, School of Nursing, Science, Associates, Health, Computer, Department of Education, Nursing Program
Skills for Utilization Review Nurse
Desired skills for utilization review nurse include:
Medicare
HIPPA and NCQA standards
Health Services policies and procedures
Medical coding
MS Office Suite
Reimbursement models
Excel
Medical management process
InterQual
PowerPoint
Desired experience for utilization review nurse includes:
Expeditiously alert providers of adverse determinations rendered by the CMO
Appropriately refer cases to re-insurance carrier
Actively participate in discharge planning processes, engaging assigned Care Manager for MLTC and DSNP members, member/family/caregiver, providers and vendors to ensure timely discharge, appropriate follow-up and continuity of care
Facilitate requests for Sub-Acute care, DME, Home Health Care and Transportation for members
Communicate with IDT as needed
Refer cases with quality of care concerns to the CMO and Quality Assurance and Performance Improvement Department
Utilization Review Nurse Examples
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Utilization Review Nurse Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of utilization review nurse. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for utilization review nurse
- Successful completion of Inter-rater reliability testing for Interqual
- Application of InterQual Criteria set and or Milliman
- Clearly document all communication and decision-making
- Provide feedback toward improving the company's overall operations and member/provider experience
- Maintain continued professional growth and education to meet continuing education requirements
- Collect information to determine appropriate protocol
- Provides telephonic assessment for injured workers in a workers compensation environment
- Evaluate, assess and implement to determine level of care
- Verify injured workers level of understanding about his /her injury and is in agreement with treatment plan
- Document the encounter into Bunch’s proprietary software system
Qualifications for utilization review nurse
- Provide the follow up and outcome information to the injured worker, employer and provider when necessary
- Supply Injured Worker with self-care instructions and contact information if necessary to call back NFR nurse
- Escalate follow-up calls if severity of illness or injury worsens
- Documentation is clear, concise and reflects technical and clinical knowledge and effective communication skills
- Contributes to overall team performance
- Flexibility for after hours coverage including nights and weekends
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Utilization Review Nurse Job Description
Job Description Example
Our growing company is looking to fill the role of utilization review nurse. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for utilization review nurse
- Assist with Triage, Utilization Review and possibly Nurse Case Management
- Review authorization requests for medical appropriateness and correct contracted vendor
- Liaison with designated Medical Director for complex authorization requests
- Responsible for presenting the clinical criteria to support denial of services
- Works with the RAC Coordinator in monitoring RAC communication via the Wachovia lockbox
- Works in conjunction with the RAC Coordinator to ensure that inpatient RAC audit requests are entered timely into RAC Manager
- Oversees RAC audit, appeal, and denial communication
- Reviews RAC denials and collaborate with PFS/HIM as needed to determine concurrence with the RAC or an appeal letter to the RAC is indicated
- Reports RAC activity at monthly revenue management meetings
- Reports any identified trends or areas of needed improvement to the Compliance Nurse Manager Auditor
Qualifications for utilization review nurse
- Maintain current nursing license and/or any professional designations that may be required with the jurisdiction
- Clinical experience with Emergency Dept, orthopedic, neurological, rehabilitation, medical/surgical, occupational health or other telephonic triage related services
- CCM, CDMS, CRRN or CPHM credentials or eligible
- Requires an LPN, LVN, or RN
- Microsoft Office experience highly preferred
- Requires walking for extended periods of time
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Utilization Review Nurse Job Description
Job Description Example
Our company is growing rapidly and is hiring for an utilization review nurse. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for utilization review nurse
- Daily interaction with department staff is that of a team player
- Engage in KePRO review activity on a consistent basis
- Successful with re-directing inpatient MRI’s to the appropriate setting at least 50% of the time and recording the in Avoidable day software
- Initial and concurrent Clinical reviews contain needed elements to sufficiently support Inpatient or Observation admission status
- The UR Specialist will conduct all negotiations for approval/authorization for services and be accountable to conduct/facilitate with the physician and or Physician Advisor in all appeals or denials received
- Demonstrate the knowledge and skills necessary to asses for patient/family discharge plan, needs and/or interventions by identifying physical, psychosocial and developmental needs and adapting plan, needs and/or interventions accordingly
- Demonstrates the knowledge and ability necessary to interpret age specific data when performing utilization reviews, relating to established criteria to affect the appropriate use of hospital services
- Introduce self to patient/family within 24 to 48 hours of identification of high risk criteria or referral for specified populations and explain Utilization Review Specialist role
- Communicating variances from the clinical path and deviations from physician’s orders to appropriate staff/physicians
- Suggesting clinical strategies to enhance the plan of care
Qualifications for utilization review nurse
- Current, valid and unrestricted state license/certification for Registered Nurse, Clinical Psychologist, or Licensed Clinical Social Worker license
- Current active unrestricted RN license to practice as a health professional within the scope of practice in the state of Kentucky and 2 years acute care clinical experience
- BSN degree or RN with BSW, BS Education, or BS in Health related field
- Registered Nurse, licensed (unrestricted) in New York State
- New York State PRI & Screen certification hospital and community recommended
- National Certification in Case Management preferred
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Utilization Review Nurse Job Description
Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of utilization review nurse. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for utilization review nurse
- Identify and maintain current information on community resources
- Maintain knowledge of current managed care contracts, federal statutes, regulations and procedures and applies them in performance of review activities
- Enhance professional knowledge and development through participation in educational program and in-service meetings and reading current literature
- Promote increased knowledge of financial implication of health care decisions by individual staff development on assigned unit(s)
- Completes mandatory education annually
- Individuals must possess these knowledge, skills and abilities and be able to explain and to demonstrate that she/she can perform the essential functions of the job, with or without reasonable accommodation, using some other combination of skills and abilities
- Graduate of an accredited School of Nursing, LPN Nursing, one-year of experience in Case Management
- Current license as Licensed Practical Nurse in Florida
- Performs all utilization review activities according to Health Services policy and procedures
- Maintains confidentiality in all aspects of operations
Qualifications for utilization review nurse
- Register Nurse with 3-5 years of clinical experience
- Current, valid and unrestricted state license/certification for Registered Nurse
- Knowledge of NCQA, health plan and CMS guidelines
- Two years medical surgical nursing and/or job related experience • Knowledge of admission practices and procedures, related laws, regulations and guidelines pertaining to hospital, homecare, long-term care, sub-acute and acute rehab operations
- Prior insurance /managed care/utilization review experience in the role of a Case Manager or Disease Manager, Population Health, Discharge Planning or Chronic Care Manager
- At least 2 years of floor nursing experience in either acute, SNF or home health a plus
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Utilization Review Nurse Job Description
Job Description Example
Our growing company is looking for an utilization review nurse. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for utilization review nurse
- Prepares report and conducts analysis of POD specific information & communication
- Supports an environment which fosters teamwork, cooperation, respect, and diversity
- Working in collaboration with denials RNs and under the general direction of the Director of Utilization Review, with oversight of authorization support staff workflows, this role is responsible to properly verify benefits, obtain authorizations, and perform assigned tasks within 72 hours of the admission date (ER visits) or earlier if possible
- Ensures all benefits, authorization requirements & status, and collection notes are obtained by working with commercial or managed care payers, documented clearly and thoroughly on accounts in the pursuit of timely reimbursement within certain established timeframes as determined by the Director
- Maintains thorough knowledge of payer guidelines, has familiarity with payer processes for initiating authorizations, and follows through accordingly to prevent loss of reimbursement
- Basic computer skills (ie
- Communicates professionally with an acceptable use of English (speaking, reading, and writing)
- Capable of working with people of diverse backgrounds
- Excellent customer service skills and great telephone etiquette
- ADN, BSN, or Diploma nursing degree
Qualifications for utilization review nurse
- NFR - Responsible for providing a telephonic assessment to the injured worker that has not yet received medical treatment
- URN - Perform prospective, concurrent and retrospective utilization management activities per specified state UR guidelines
- Three years nursing experience in acute care setting, Utilization Review experience preferred
- Demonstrates an ability to organize, perform and track multiple tasks accurately in short timeframes of one continuously scheduled shift or less
- Certification in Case Management, Nursing, or Utilization Review, preferred not required
- Associates degree, diploma or B.S