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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 comprehensive expertise in Utilization Management (UM), medical necessity assessments, and patient status evaluations. This role is pivotal in supporting the UM program by establishing and sustaining effective 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 data tracking, evaluation, and reporting. This individual plays an active 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 ascertain the appropriate admission status for patients.
- Conducts ongoing clinical evaluations to ensure continued medical necessity.
- Identifies and escalates cases requiring secondary review to Case Management leadership or Medical Directors.
- Facilitates accurate provider documentation to reflect patient severity and risk appropriately.
- Maintains cooperative relationships with healthcare providers, case management personnel, and compliance teams.
- Responsible for submitting clinical data and managing 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 while navigating the unique requirements of reimbursement systems.
- Supports providers in achieving accurate clinical documentation to optimize reimbursement outcomes.
- Stays informed on UR practices, reimbursement modalities, and relevant clinical and legal matters affecting patient care.
- Provides management with workflow reports to analyze productivity, quality, and utilization trends.
- Participates in the design, execution, and continuous improvement of initiatives aimed at enhancing quality and cost-effectiveness.
- Ensures thorough documentation aligns with departmental standards.
- Coordinates educational sessions for staff regarding utilization management processes and regulatory changes.
- Offers mentorship and orientation 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.
- Experience in Case Management for at least 1 year.
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 health and well-being across the communities we serve.
