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Clinical Utilization Review Nurse
2 months ago
We are seeking a skilled Clinical Utilization Review Nurse to join our team at Ascension Seton Northwest. As a Utilization Review Registered Nurse, you will play a critical role in ensuring the quality and efficiency of our healthcare services.
Key Responsibilities- Conduct thorough reviews of patient admissions and service requests to determine medical necessity and compliance with reimbursement policy criteria.
- Provide case management and consultation services for complex cases, working closely with healthcare teams to develop effective care plans.
- Assist departmental staff with coding, medical records, precertification, reimbursement, and claim denials/appeals.
- Coordinate discharge planning needs with healthcare team members, ensuring a smooth transition for patients.
- Prepare statistical analysis and utilization review reports as needed, providing valuable insights for quality improvement.
- Oversee and coordinate compliance with federally mandated and third-party payer utilization management rules and regulations.
- Registered Nurse licensure required, relevant to the state in which work is performed.
- Diploma from an accredited school/college of nursing or required professional licensure at time of hire.
- RN Compact License required.
- Bachelor's degree in Nursing preferred.
- Three years of clinical experience preferred.
- Two to three years of utilization management and managed care experience preferred.
