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Clinical Utilization Review Nurse
2 months 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 extensive expertise in Utilization Management (UM), medical necessity evaluations, and patient status assessments. This role is pivotal in supporting the UM program by establishing and sustaining effective and efficient protocols for determining appropriate admission statuses in alignment 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 data tracking, evaluation, and reporting. This individual actively engages 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 confirm that medical necessity criteria are satisfied.
- Performs a clinical review of patient medical records to ascertain the appropriate admission status.
- Conducts ongoing clinical assessments to evaluate continued medical necessity.
- Identifies and escalates cases and issues suitable for secondary review to Case Management leadership or Physician Advisors.
- Facilitates accurate provider documentation to reflect patient severity and risk accurately.
- Maintains cooperative relationships with providers, case management personnel, clinics, and compliance teams.
- Responsible for submitting clinical data and entering authorizations for both concurrent and post-discharge hospital stays.
- Collaborates with providers and various departments regarding medical necessity matters.
- Adheres to applicable state and federal regulations as well as specific reimbursement system requirements.
- Supports providers in ensuring compliant clinical documentation to optimize reimbursement.
- Stays informed about current UR practices, reimbursement modalities, and relevant clinical and legal issues.
- Provides leadership with workflow reports to analyze productivity, quality, and utilization trends.
- Participates in the development and implementation of initiatives aimed at enhancing quality and cost-effectiveness.
- Documents thoroughly and clearly according to established departmental standards.
- Coordinates educational opportunities for staff and healthcare providers regarding utilization management processes.
- Offers orientation and mentorship to new team members.
- Timely escalates issues to the Case Management team or leadership.
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 Swedish Health Services:
Swedish Health Services is committed to delivering exceptional healthcare and fostering an inclusive environment where diversity is valued. We are dedicated to supporting our caregivers in their professional growth while ensuring the highest quality of care for our patients.
