RN Utilization Review Specialist

5 days ago


Greensboro, North Carolina, United States Cone Health Employee Health & Wellness Full time
Job Summary

Cone Health Employee Health & Wellness is seeking a skilled RN Utilization Review Specialist to join our team. As a key member of our Utilization Review team, you will play a critical role in ensuring the medical necessity of hospital admissions, appropriate levels of care, and continued stays.

Responsibilities
  • Conduct initial case reviews within 24-48 hours of admission for all inpatients, utilizing criteria accepted by Cone Health as defined in the departmental Utilization Management Plan.
  • Subsequent reviews will be conducted as long as the patient remains in the hospital, following required government rules and regulations and/or third-party payor rules and regulations.
  • Observation cases will be reviewed daily to assess the need for continued observation, conversion to inpatient status, or discharge.
  • Communicate all review outcomes to all relevant parties, including medical staff and hospital staff.
  • Evaluate for discharge planning needs of patients and make appropriate and timely referrals to the transition of care team.
  • Collaborate with the care team in developing and expanding the plan of care to encompass multidisciplinary patient care needs.
  • Routinely refer appropriate issues/cases to the Department?s Physician Advisor in a timely manner.
  • Provide oversight of utilization of resources and accurately identify issues surrounding the appropriate utilization of resources.
  • Document and complete code 44 process and avoidable days prior to the patient?s discharge.
Qualifications
  • Required: Bachelor?s degree in nursing or healthcare-related field, at least three (3) years acute nursing experience, and working knowledge of computers and basic software applications.
  • Preferred: Three (3) or more years in Utilization Review utilizing national evidence-based clinical support software, working understanding and requirements for health plan utilization management, and RN | Registered Nurse licensed in North Carolina or a Compact state.


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