Clinical Utilization Review Nurse

2 weeks ago


Spring Hill, Florida, United States The Tampa General Hospital Full time
Clinical Utilization Review Nurse

The Tampa General Hospital is a comprehensive healthcare facility that provides a wide range of services, including a surgery program, a specialized orthopedic joint replacement center, and advanced cardiac care. Our institution is recognized as an Accredited Chest Pain Center and a Primary Stroke Center, ensuring the highest standards of patient care.

This role is situated within our utilization review department, focusing on the assessment of patient admissions and ongoing care needs. The Clinical Utilization Review Nurse will engage in the following responsibilities:

  • Conduct Initial Assessments: Perform clinical evaluations and continued stay assessments using evidence-based criteria to determine medical necessity for hospitalized patients.
  • Collaborate with Medical Staff: Engage in discussions with physicians to gather necessary documentation that supports hospital admissions and discharge requirements.
  • Escalate Complex Cases: Refer cases to the Utilization Review Manager or Physician Advisor when additional information is needed to justify medical necessity.
  • Document Activities: Maintain thorough records of all actions taken within the case management software, including clinical reviews and payer communications.
  • Manage Concurrent Denials: Review and address concurrent denials by coordinating internal reviews and facilitating Peer to Peer discussions as necessary.
  • Support Emergency Admissions: Collaborate with emergency department staff to assess potential admissions and ensure proper documentation for inpatient or outpatient care.

Key Responsibilities:

  • Review medical records to confirm indicators of medical necessity and collaborate with the healthcare team to ensure accurate documentation.
  • Educate medical staff on appropriate documentation practices to support the level of care.
  • Communicate effectively with case managers and other healthcare professionals to ensure cohesive patient care management.
  • Perform additional duties as assigned.

Qualifications:

  • Active Florida Registered Nurse License.
  • A minimum of 5 years of acute care experience, with at least 2 years in a case management role.
  • Preferred experience in case management within an acute care hospital setting.
  • Knowledge of discharge planning processes.

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