Utilization Review Nurse- Full Time

Facility:

Work From Home - Ohio

Department:

Utilization Review Team

Schedule:

Full time

Hours:

40

Job Details:

Under the supervision of the Manager of Utilization Management, the Utilization Review RN conducts medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, Joint Commission, CMS, and other agencies. Prospectively, concurrently, or retrospectively determines the appropriateness of inpatient, observation, and extended recovery services following review of relevant medical documentation and medical
guidelines and communicates information to payers in accordance with contractual obligations. The

Utilization Review RN serves as a resource to the physicians, collaborates with the Care Manager in the development and implementation of the plan of care, and collaborates with the Denials team assisting to prevent concurrent and retrospective denials. The Physician Advisor role will support the Utilization Review RN for second level clinical reviews for cases that do not meet medical criteria, complex cases, appropriate level of care, Medicare cases as required, and the need for Peer-to-Peer reviews. Collaboration with Physician Advisor will support policy development, process improvement, and staff education related to clinical denial mitigation.

Department Specific Job Details:

Shift

• Flexible schedule evenings until 12am
• 12 or 10 hour shifts available

Education

• Completion of accredited RN program with current RN license in Ohio (required)
• Graduate of an accredited  BSN Nursing Program (required)

Experience

• Two years’ experience required in the acute care setting, preferably in pediatrics.
• Current knowledge of reimbursement requirements, level of care criteria, APR-DRGs, MCG guidelines
• Exceptional oral and written communication skills
• Proficiency in Microsoft Word, Excel, PowerPoint and Epic Systems (preferred)

Education Requirements:

Bachelors: Nursing (Required)

Certification/License Requirements:

[Lic] RN: Registered Nurse (RN) - Ohio Board of Nursing, MCG Care Guidelines Specialist - ISC/GRC - Milliman Care Guidelines - MCG Health