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Clinical Utilization Review Nurse
2 months ago
Position Overview
Remote - Clinical Utilization Review RN
On Call/Per Diem
The Clinical Utilization Review (UR) Nurse possesses a robust clinical foundation complemented by extensive expertise in Utilization Management (UM), medical necessity evaluations, and patient status assessments. This role is integral to the UM program, focusing on the establishment and maintenance of efficient processes for determining appropriate admission statuses in accordance with regulatory and reimbursement standards set by both commercial and government payers.
The UR Nurse is tasked with conducting admission, concurrent, and retrospective reviews to ensure accurate tracking, evaluation, and reporting of relevant data. This position actively engages in initiatives aimed at process enhancement, collaborating with various departments and multidisciplinary teams.
Key Responsibilities:
- Engage in collaboration and consultation with relevant departments and healthcare providers to verify that medical necessity criteria are satisfied.
- Perform clinical assessments of medical records to ascertain the admission status of patients.
- Conduct ongoing clinical evaluations to determine continued medical necessity.
- Identify and report cases requiring secondary review to Case Management leadership or the Medical Director.
- Facilitate accurate provider documentation to reflect patient severity and risk appropriately.
- Maintain cooperative relationships with providers, case management personnel, clinics, and compliance teams.
- Oversee the submission of clinical data and the entry of authorizations for both concurrent and post-discharge hospital stays, including conducting appeals as necessary.
- Collaborate with various stakeholders, including compliance, contracting, and internal/external Physician Advisors, on medical necessity issues.
- Adhere to applicable state and federal regulations as well as specific reimbursement system requirements.
- Support accurate clinical documentation by providing concurrent assistance to providers to enhance reimbursement outcomes.
- Stay informed on UR developments to understand reimbursement modalities and relevant clinical/legal matters affecting patients and care providers.
- Provide leadership with workflow reports to assess productivity, quality issues, utilization trends, and denial patterns.
- Participate in the creation, execution, evaluation, and ongoing refinement of initiatives aimed at improving quality, continuity, and cost-effectiveness.
- Deliver comprehensive documentation in line with established departmental standards.
- Coordinate training and education for staff and healthcare providers regarding the utilization management process, including reimbursement trends and regulatory changes.
- Offer orientation and mentorship to new team members.
- Timely escalate issues to the Case Management team or leadership as required.
- Demonstrate proficiency in operating essential equipment and software, including data entry systems and clinical management software.
Qualifications:
- Bachelor's Degree in Nursing (BSN) from an accredited institution.
- Current 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
Swedish Health Services is committed to providing high-quality healthcare and 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.
