UTILIZATION REVIEW NURSE

4 weeks ago


San Angelo TX USA, United States Shannon Health Full time
Job Summary

The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. He/she actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. This individual maintains current and accurate knowledge regarding commercial and government payers and CIHQ regulations/guidelines/criteria related to UM. The UR Nurse effectively and efficiently manages a diverse workload in a dynamic regulatory environment. The UR Nurse is a member of, and provides support to, the hospital's UR Committee. He/she collaborates with multiple leaders at various levels throughout Shannon Health, for the purpose of supporting and improving the UM program.

Education

Education Type

Program of Study

Required/Preferred

High School Diploma

N/A

Required

Associate's degree

Nursing

Required

Bachelor's degree

Nursing

Preferred

Experience

Number of Years

Type of Experience

Required/Preferred

5 Years

Clinical nursing

Required

1 Year

Inpatient Utilization Review

Preferred

Certification & Licensures

Certification/Licensure Type

Required/Preferred

Registered Nurse (RN),

with Authorization to Practice in the State of Texas

Required

ACM (Accredited Case Manager) through ACMA

Preferred

CCM (Certified Case Manager) through CCMC

Preferred

*Must obtain within ninety (90) days of hire

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