RN-Utilization Review Specialist

4 weeks ago


Memphis, Tennessee, United States Baptist Memorial Full time
Job Summary

As a Utilization Review Nurse, you will play a critical role in ensuring the medical necessity and appropriateness of healthcare services and treatment. You will work closely with providers, insurance companies, and patients to ensure cost-effective and appropriate care.

Responsibilities
  • Completes and enters inpatient and observation admission reviews against standard criteria per payer guidelines
  • Prioritizes observation case reviews
  • Assists with level of care in collaboration with attending providers
  • 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
  • Experience Minimum: RN with 3 years of clinical experience
  • Experience Preferred: RN with 3 years of clinical experience
  • Education Minimum: Diploma or Associate Degree in Nursing
  • Education Preferred: BSN or MSN
  • Special Skills Minimum: Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills. Problem solving; and knowledge of governmental regulations.
  • Licensure Minimum: RN
  • Licensure Preferred: CCM;ACM
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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