Utilization Review Nurse RN

Contract Length: 13 weeks

Hours: 40 hours/week

Shifts: Days/Eves 8:00-4:30 or 4:30-1:00am, every other weekend

Position Summary

The Utilization Review (UR) Registered Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities. The RN conducts timely reviews of inpatient and outpatient medical records to determine the appropriateness of admissions, continued stays, and the level of care using established criteria and guidelines. This role collaborates with healthcare providers, patients, payers, and internal departments to ensure quality care while optimizing resource utilization and controlling costs.

Job Duties

1. Assessment: Collects, reviews, and documents clinical data relevant to utilization management, including patient status, treatment plans, and healthcare utilization. Applies nationally recognized criteria to assess the appropriateness of services.
2. Outcomes Identification: Identifies expected outcomes related to care transitions, resource use, and reimbursement to optimize patient health outcomes and reduce unnecessary utilization.
3. Planning: Develops a utilization management plan by coordinating with clinical teams, payers, and discharge planners to support timely care progression and appropriate resource use.
4. Implementation: Implements review processes to evaluate necessity and efficiency of services. Initiates communication with physicians and payers to resolve authorization issues and prevent delays in care.
5. Evaluation: Continuously evaluates the appropriateness of hospital admissions, continued stays, and treatment plans in accordance with payer guidelines and evidence-based practice.
6. Quality of Practice: Promotes quality through evidence-based utilization review processes and actively contributes to performance improvement initiatives.
7. Education: Attains and maintains current knowledge in UR/UM practices, payer requirements, clinical guidelines, and regulations affecting utilization management.
8. Collegiality: Collaborates with nursing, providers, case management, finance, and payer representatives. Contributes to professional development by sharing knowledge and supporting team education.
9. Collaboration: Utilizes principles of relationship-based care to collaborate with care teams, patients, families, and external entities to facilitate effective care coordination and appropriate resource utilization.
10. Ethics: Applies ethical decision-making when handling authorization issues, appeals, and coverage decisions. Advocates for patient needs while balancing organizational goals and payer requirements.
11. Evidence-Based Nursing Practice and Nursing Research: Applies evidence-based criteria for utilization review decisions. Supports data collection and reporting to enhance outcomes.
12. Resource Utilization: Considers safety, effectiveness, cost, and legal compliance when recommending levels of care or authorizations. Ensures documentation supports accurate coding, billing, and compliance.

Requirements 

• Graduation from an accredited school of nursing as a registered nurse.

• Must have 3 years of acute care clinical nursing experience or recent experience in utilization review. OR An approved equivalent combination of education and experience.

• Must go to all 3 units – Inpatient, Psych, Emergency Department

  Possible Option to be Remote after training