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Clinical Utilization Review Nurse
2 months ago
The Clinical Utilization Review Nurse plays a pivotal role in the healthcare system, combining clinical expertise with a comprehensive understanding of Utilization Management (UM) processes. This position is essential for evaluating medical necessity and determining patient status in accordance with both regulatory and reimbursement standards.
Key Responsibilities:
- Conduct admission, concurrent, and retrospective reviews to ensure compliance with medical necessity criteria.
- Collaborate with multidisciplinary teams to enhance the UM program and streamline processes.
- Perform thorough clinical assessments of medical records to ascertain appropriate admission status.
- Engage in ongoing clinical reviews to evaluate the necessity of continued care.
- Identify and escalate cases requiring secondary review to leadership and appropriate medical personnel.
- Support accurate provider documentation to reflect patient severity and risk levels.
- Maintain effective communication with case management, revenue cycle teams, and payer compliance units.
- Facilitate the submission of clinical data and authorizations for both concurrent and post-discharge hospital stays.
- Stay updated on state and federal regulations impacting reimbursement and clinical practices.
- Provide educational resources and training to staff regarding UM processes and regulatory changes.
Qualifications:
- Bachelor's Degree in Nursing (BSN) from an accredited institution.
- Current Registered Nurse License in Washington State.
- A minimum of three years of experience in Medical/Surgical nursing.
- At least one year of experience in Utilization Review nursing.
Preferred Qualifications:
- Certification in ACM or CCM.
- Experience in Case Management.
Why Work with Us:
At Swedish Health Services, we are committed to providing a supportive environment that fosters professional growth and development. Our comprehensive benefits package is designed to promote well-being and financial security for our employees and their families. We believe in the importance of diversity and inclusivity in the workplace, ensuring that every team member feels valued and respected.
