Utilization Review Nurse

General Information:

Job title: Utilization Review Nurse

Schedule: Full-time, 80 hours per pay period

Weekend rotation: None required

Holiday rotation: None required

Position Summary:

The Utilization Review Nurse position plays a critical role in ensuring the appropriate use of healthcare resources while maintaining high-quality patient care. This position is responsible for conducting utilization reviews, assisting with resolving inpatient and OBS payment issues/denials, and providing administrative support to Quality and Revenue Cycle departments.

Position Responsibilities:

1. Obtain prior authorization and timely insurance notification.
2. Communicate Provider plans to notify insurance entities.
3. Evaluate and intervene, if necessary, the appropriateness of admission and placement using MCG Guidelines in conjunction with documentation in the patient's medical record.
4. Coordinate with Hospitalist and care manager to facilitate timely discharge of patients.
5. Coordinate as appropriate with Denial and Appeals management, Case Manager, Patient Accounts, and other necessary parties for denials, appeals, and medical necessity reviews.
6. Validate correct insurance information is on file and work with registration to correct any incorrect information.
7. Provide financial information and resources to uninsured/underinsured patients.
8. Monitor for timely and accurate completion of regulatory forms that apply to the role (MOON forms etc.).
9. Identify, analyze, and interpret data from a variety of clinical and financial sources.
10. Prepare reports and information for Utilization Review meetings.
11. Perform other duties as requested.

Position Requirements:

1. Two-year degree in nursing required; four-year degree in nursing preferred.
2. Must hold and maintain a nursing license. RNs with an active Compact Licensure are to obtain a Wisconsin RN license within 90 days of relocation.
3. BLS within 6 months of hire.
4. 1+ years of related work experience required.
5. Exceptional accuracy and attention to detail required.

Knowledge, Skills, & Abilities:

1. Physical strength and dexterity to operate necessary machinery and perform all required cleaning duties.
2. Ability to read any special instructions and to understand labels on cleaning products.
3. Self-starter with excellent interpersonal communication skills.
4. Ability to have continuous oral and written communication with co-workers and supervisors is essential.