Clinical Utilization Review Nurse
1 week ago
Position Overview
Remote - Clinical Utilization Review Nurse
On-call/Per diem
The Clinical Utilization Review (UR) Nurse possesses a robust clinical foundation combined with comprehensive expertise in Utilization Management (UM), medical necessity evaluation, and patient status assessment. This role is integral to the UM program, focusing on the development and maintenance of efficient processes to ascertain appropriate admission statuses in alignment with regulatory and reimbursement standards set by both commercial and governmental payers.
The UR Nurse is tasked with conducting admission, concurrent, and retrospective reviews to ensure accurate tracking, evaluation, and reporting of relevant data. This individual plays a key role in process enhancement initiatives, collaborating with various departments and multidisciplinary teams.
Key Responsibilities:
- Engages in collaboration and consultation with relevant departments and healthcare providers to verify that medical necessity criteria are satisfied.
- Performs clinical assessments of medical records to determine patient admission status.
- Conducts ongoing clinical evaluations to ensure continued medical necessity.
- Identifies and escalates cases requiring secondary review to Case Management leadership or the Medical Director.
- Facilitates precise provider documentation to accurately reflect patient severity and risk levels.
- Maintains productive relationships with healthcare providers, case management personnel, clinics, and compliance teams.
- Responsible for submitting clinical data and processing authorizations for both concurrent and post-discharge hospital stays.
- Collaborates with various stakeholders, including compliance and revenue cycle teams, to address medical necessity issues.
- Adheres to applicable state and federal regulations, as well as unique reimbursement system requirements.
- Supports providers in optimizing reimbursement through accurate clinical documentation.
- Stays informed on UR practices, reimbursement modalities, and relevant clinical and legal matters.
- Provides leadership with workflow reports to analyze productivity, quality, and utilization trends.
- Participates in the creation, implementation, and ongoing refinement of initiatives aimed at enhancing quality and cost-effectiveness.
- Documents findings in accordance with established departmental standards.
- Coordinates training and educational sessions for staff and healthcare providers regarding utilization management processes.
- Offers orientation and mentorship to new team members.
- Timely escalation of issues to Case Management leadership as necessary.
- Demonstrates proficiency in operating essential office equipment and software.
Qualifications:
- Bachelor's Degree in Nursing (BSN) from an accredited institution.
- Active Registered Nurse License in Washington State upon hire.
- A minimum of 3 years of experience in Medical/Surgical nursing.
- At least 1 year of experience in Utilization Review nursing.
Preferred Qualifications:
- ACM or CCM certification upon hire.
- 1 year of experience in Case Management.
About the Organization
At Swedish Health Services, we are committed to delivering exceptional healthcare services while fostering an inclusive workplace where diversity is valued. Our caregivers are essential to our mission of improving the health and wellbeing of the communities we serve.
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Seattle, Washington, United States Swedish Health Services Full timePosition Overview Remote - Clinical Utilization Review Nurse On Call/Per Diem The Clinical Utilization Review (UR) Nurse possesses a robust clinical foundation combined with comprehensive expertise in Utilization Management (UM), medical necessity assessments, and patient status evaluations. This role is pivotal in supporting the UM program by establishing...
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