RN-Utilization Review Specialist
5 days ago
Job Summary:
The Utilization Review Nurse is responsible for evaluating the medical necessity and appropriateness of healthcare services and treatment as prescribed by utilization review standards. This role works with providers, insurance companies, and patients to ensure cost-effective and appropriate care.
Responsibilities:
- Completes and enters inpatient and observation admission review against standard criteria per payer guidelines
- Prioritizes observation case review
- Assists with level of care in collaboration with attending provider
- Enters working diagnosis-related groups (DRGs) in the electronic medical record
- Submits clinical information to payer per payer requirements
- Completes continued stay reviews every 3 days or more often if required
- Communicates with care coordinators for authorized days, level of care, medical necessity, or other areas when indicated
- Communicates with physician advisors related to status concerns or denials
- Updates auth/cert screen in the electronic medical record
- Works assigned queues in the electronic medical record
- Communicates with authorization coordinator
- Communicates in-house high dollar case information
- Completes assigned goals
Requirements, Preferences, and Experience:
- RN with 3 years of clinical experience
- Critical thinking skills, clinical knowledge, attention to detail, communication, organization, interpersonal, time management, and computer skills
- Problem-solving and knowledge of governmental regulations
About Baptist Memorial Health Care:
Baptist Memorial Health Care is a leading healthcare provider in the Mid-South region. We offer a competitive compensation and benefits package, including paid vacation/time off, continuing education opportunities, and a generous retirement plan.
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