Utilization Review Nurse

Position Summary: Reviews patient admissions for appropriateness, efficiency of resource utilization and compliance with third party payer requirements. Duties include analyzing medical charts, determining whether care provided is within established parameters.

Job Requirement

Education/Experience:
Graduation from an accredited school of nursing and five (5) years of acute hospital clinical nursing experience, one (1) year of which was in Utilization Management, Case Management, or Clinical Documentation Improvement.

Licensing/Certification Requirements:
Valid license by the State of Nevada to practice as a Registered Nurse.

Additional Position Requirements

• Minimum three (3) years of Utilization Management experience.
• Minimum of three (3) year's experience with discharge planning in an acute care facility.
• Recent documented experience with InterQual, and ability to pass the InterQual exam.
• Recent documented experience with Milliman experience.

Knowledge, Skills, Abilities, and Physical Requirements

Knowledge of:
Interquel or Milliman utilization review criteria, Medicare/Medicaid guidelines, hospital policies and procedures; Joint Commission Accredited Health care Organizations standards, state statutes governing hospital services and health care, and other relevant regulations and standards; clinical medical and nursing procedures; disease processes; department and hospital safety practices and principles; patient rights; age specific patient care practices; infection control policies and practices; department and hospital emergency response policies and procedures.

Skill in:
Interpreting patient charts to determine whether care given is within best practice, appropriate for the diagnosis and properly documented; excellent ability to collaborate, co-ordinate and communicate findings; interpreting regulations and standards for others; writing reports, meeting minutes and other technical documents; analyzing statistical and other quantitative data; applying investigative and interviewing techniques; using a computer and a variety of software applications; communicating with a wide variety and establishing interpersonal relationships to interact effectively with co-workers, supervisor, staff in other work units and exchange or convey information.

Physical Requirements and Working Conditions:
Mobility to work in a typical office setting and use standard equipment, stamina to remain seated for extended periods of time, vision to read printed materials and a computer screen, and hearing and speech to communicate effectively in person and over the telephone. Strength and agility to exert up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. May work shifts and weekends. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this classification.

Originally posted on Himalayas