Utilization Review RN

2 weeks ago

Richmond VA United States Virginia Commonwealth University Health System Full time

The Utilization Review RN is responsible for utilization management and utilization review for prospective, concurrent, or retrospective review.

This position functions as a part of a multidisciplinary team, including physicians, social workers, discharge planning assistants and payers. The Utilization Review RN performs reviews of current inpatient services, and determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

The Utilization Review RN conducts prospective, concurrent and retrospective utilization review for inpatient services, observations, as well as specific outpatient service requests.

Licensure, Certification, or Registration Requirements for Hire: Licensed Registered Nurse in the State of Virginia or eligible Licensure, Certification, or Registration Requirements for continued employment: Current RN licensure in Virginia Complete 15 Continuing Education Units per year Experience REQUIRED: Minimum of three (3) years of nursing experience in an acute care setting Experience PREFERRED One (1) year of Care Coordination experience Clinical experience with specialty patient population Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc.). Proficient in Milliman Care Guidelines (MCG) or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management. Education/training REQUIRED: Bachelors of Science in Nursing from an accredited School of Nursing Education/training PREFERRED: Master's Degree in Nursing or a healthcare related field from an accredited program Case Management Certification Independent action(s) required: Works with the attending and consulting physicians to facilitate effective and efficient transition through the process of hospitalization. Works collaboratively with all members of the multi-disciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum, as well as appropriately reimbursed by payers as contracted, and that resources are efficiently and effectively utilized. Utilizes medical necessity criteria as a tool to assess appropriateness of level and setting of care, assists in the denial and appeals process, assesses quality, and identifies and reports potential risk management issues. Responsible for participation in and completion of all patient safety initiatives appropriate to the position. Establishes and maintains a professional rapport with providers, patients/families, and internal customers. Trains and educates new UM staff nurses and new RN Care Coordinators by demonstrating job competency, providing technical instruction and leadership and generally raising the level of performance of others (within and outside of the department) Advocates that the patient is placed in the status and level of care for appropriate remuneration of services rendered. Utilizes clinical application systems with fundamental proficiency in utilization review systems and uses business support applications as needed Supervisory responsibilities (if applicable): N/A Additional position requirements: Ability to flex the schedule as needed to meet the demands of the department Age Specific groups served: All Physical Requirements (includes use of assistance devices as appropriate): Physical Lifting 20-50 lbs. Activities: Prolonged sitting, Repetitive motion Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking Emotional: Fast pace environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Able to adapt to frequent change

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.

  • RN - Utilization Review

    2 weeks ago

    Medford, OR, United States Health Advocates Network Full time

    Health Advocates Network is urgently hiring Utilization Review Registered Nurses (RNs) in the Medford, OR area. Must have 2 years of Discharge Planning and Utilization Review experience. + Pay Rate: $2,760 weekly + Specialty: Utilization Review Registered Nurse (RN) + Shift Info: Day + 13 Week Contracts and more available! RN Qualification and...

  • Utilization Review RN

    5 days ago

    Houston, TX, United States CHI Saint Luke's Hospital at the Vintage Full time

    Utilization Review RNOverview Baylor St. Luke's Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke's Health. Located in the Texas Medical Center, the hospital is the home of the Texas Heart Institute, a cardiovascular research and education institution founded in...

  • Utilization Review Nurse

    1 month ago

    Meadowbrook, PA, United States Holy Redeemer Hospital and Medical Center Full time

    Utilization Review NursePer Diem 1648 Huntingdon Pike Nursing RN/LPN Day SUMMARY OF JOB: To review each admission for appropriate assignment of level of care based upon clinical guidelines as well as to review documentation for continued stays daily and provide clinical information including assessments and outcomes for all payers and all levels of care...

  • Utilization Review RN- Onsite

    4 weeks ago

    Plattsburgh, NY, United States The University of Vermont Health Network Full time

    Please Note: This is an onsite position supporting the Emergency Department at Champlain Valley Physicians Hospital (CVPH) in Plattsburgh, NY.GENERAL SUMMARY:The Utilization Review RN monitors, collects and analyzes data and evaluates variances of resource utilization, complications and overall quality of care based on benchmarked criteria or established...

  • Utilization Review RN- Onsite

    1 month ago

    Plattsburgh, NY, United States The University of Vermont Health Network Full time

    Please Note: This is an onsite position supporting the Emergency Department at Champlain Valley Physicians Hospital (CVPH) in Plattsburgh, NY.GENERAL SUMMARY:The Utilization Review RN monitors, collects and analyzes data and evaluates variances of resource utilization, complications and overall quality of care based on benchmarked criteria or established...

  • UTILIZATION REVIEW NURSE

    2 weeks ago

    Randallstown, MD, United States LifeBridge Health Full time

    UTILIZATION REVIEW NURSE (RN)Randallstown, MDNORTHWEST HOSPITALNW CARE MANAGEMENTFull-time - Day shift - 8:00am-4:30pmRN Other81988Posted:March 21, 2024Apply NowSave JobSavedSummaryPosition Summary:Conducts concurrent and retrospective chart review for clinical, financial and resource utilization information. Provides intervention and coordination to...

  • Utilization review Nurse

    2 weeks ago

    , MI, United States LanceSoft Inc Full time

    Job Description:This position will be remote role for Nurses in MichiganShould have a valid MI RN LicenseShould Have utilization management experience.Should have experience completing post-acute reviews for the inpatient rehab, skilled nursing facility settings previously.The candidate should be well versed in coordination of care activities along with...

  • RN Case Manager/UR Reviewer

    5 days ago

    Lubbock, TX, United States Lubbock Heart Hospital Full time

    RN Case Manager/UR ReviewerJOIN OUR TEAM!!! Are you looking to be one of the team? To be part of the family and not just another number? Are you looking for a positive work environment where teamwork and diversity are key? We value your contributions. Every role in our hospital has an impact on each of our patients. We work hard to make sure our employees...

  • UTILIZATION REVIEW NURSE

    2 weeks ago

    Baltimore, MD, United States LifeBridge Health Full time

    UTILIZATION REVIEW NURSE (RN) - PRNBaltimore, MDSINAI HOSPITALUTILIZATION REVIEWPRN - As Needed - 8:00am-4:30pmRN Other82413Posted:March 21, 2024Apply NowSave JobSavedSummaryPosition Summary:Conducts concurrent and retrospective chart review for clinical, financial and resource utilization information. Provides intervention and coordination to decrease...

  • Utilization Reviewer

    1 month ago

    Topeka, KS, United States Pathway Family Services LLC Full time

    Description ****Average hourly rate is $22.60 (including wage, incentives, bonuses, overtime, shift differential, etc.)****      Utilization ReviewerPathway Family Services, LLC. provides resources for youth and families through their Independent Living Program, TRAIL (Teens Reaching Adult Independent Living), Psychiatric Residential Treatment Facility,...

  • Utilization Review Nurse

    2 weeks ago

    Portland, ME, United States Martin's Point Health Care Full time

    Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an...

  • Utilization Review, Registered Nurse

    2 weeks ago

    Syracuse, NY, United States Nascentia Health Full time

    The Utilization Review Nurse assists the utilization review process taking on various tasks including data collection of demographic, claim and medical information; analysis; and outcomes reporting. Utilizes standards of care, evidence based practices, Medicare and Medicaid and organizational coverage guidelines to assure members receive high quality, cost...

  • Utilization Review Nurse

    2 weeks ago

    Huntsville, TX, United States Huntsville Memorial Hospital Full time

    Under general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and...

  • Travel Nurse RN

    3 days ago

    Baltimore, MD, United States Health Advocates Network-Nursing Full time

    Health Advocates Network-Nursing is seeking a travel nurse RN Utilization Review for a travel nursing job in Baltimore, Maryland.Job Description & RequirementsSpecialty: Utilization ReviewDiscipline: RNStart Date: 06/17/2024Duration: 14 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelHealth Advocates Network is urgently hiring Utilization...

  • Utilization Review Coordinator

    4 days ago

    Fresno, CA, United States Community Health System - CA Full time

    Overview: *All positions are located in Fresno/Clovis CA**Up to $25K in bonus incentives (sign-on and relocation)*Opportunities for you!Join a Forbes Top 10 CA Employer!Direct impact on quality patient careTime and a half after 8 hrs + weekend and night differential (call pay for procedural areas)Free Continuing Education and certification including BLS,...

  • Travel Nurse RN

    4 hours ago

    Irving, TX, United States TRS Healthcare Full time

    TRS Healthcare is seeking a travel nurse RN Utilization Review for a travel nursing job in Irving, Texas.Job Description & RequirementsSpecialty: Utilization ReviewDiscipline: RNStart Date: 06/17/2024Duration: 12 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelTRS Healthcare Job ID #1152889. Pay package is based on 8 hour shifts and 40 hours...

  • Case Manager/Utilization Review RN

    2 weeks ago

    Pasco, WA, United States Lourdes Health Full time

    Education & Qualifications: Graduate from an accredited school of nursing (RN) required, bachelors preferred. Knowledge and skills necessary to provide care appropriate to the population served in the CM Department. Two (2) or more year’s clinical experience preferred. Acute care or community social agency case management experience preferred. Utilization...

  • Travel Nurse RN

    3 days ago

    Syracuse, NY, United States Supplemental Health Care Full time

    Supplemental Health Care is seeking a travel nurse RN Utilization Review for a travel nursing job in Syracuse, New York.Job Description & RequirementsSpecialty: Utilization ReviewDiscipline: RNStart Date: ASAPDuration: 13 weeksEmployment Type: TravelJob Description:Supplemental Health Care is seeking Utilization Review RNs in Syracuse, New York for a 16-week...

  • Travel Nurse RN

    3 days ago

    Hartford, CT, United States Supplemental Health Care Full time

    Supplemental Health Care is seeking a travel nurse RN Utilization Review for a travel nursing job in Hartford, Connecticut.Job Description & RequirementsSpecialty: Utilization ReviewDiscipline: RNStart Date: ASAPDuration: 13 weeksEmployment Type: TravelJob Description:As one of the largest Healthcare jobs placement agencies in the U.S., Supplemental Health...

  • Travel Nurse RN

    3 days ago

    Charlottesville, VA, United States Medical Solutions Full time

    Medical Solutions is seeking a travel nurse RN Case Manager, Utilization Review for a travel nursing job in Charlottesville, Virginia.Job Description & RequirementsSpecialty: Utilization ReviewDiscipline: RNDuration: 13 weeks40 hours per weekShift: 10 hours, daysEmployment Type: Travel We’re seeking talented healthcare professionals whose...