Clinical Utilization Review Nurse

3 weeks ago


Batesville, Arkansas, United States White River Medical Center (Health System) Full time
Job Summary:

The UR nurse will review physician orders, documentation, and test results, utilizing evidence-based tools, critical thinking skills, and nursing expertise to ensure providers have the most up-to-date recommendations. The recommendations and guidance provided will allow providers to develop a plan of care for the patient in the appropriate status, based on medical necessity, and guide applicable and accurate documentation to support the care provided.

Key Responsibilities:
  • Identify opportunities for performance improvement and implement changes to enhance patient care and outcomes.
  • Perform admission reviews using MCG/Indicia Care Guidelines to facilitate medical necessity and ensure accurate documentation.
  • Monitor patients for medical necessity, taking necessary action to include issuing ABNs or HINNs and appropriately documenting.
  • Communicate with the healthcare team to eliminate or minimize delays in service requests or treatment.
  • Utilize condition code 44 guidelines when appropriate and send clinical information to payers as requested/required.
  • Assist in discharge planning resources and plans from the ED as needed.
  • Perform other duties as assigned by supervision.
Requirements:
  • RN licensure required (Bachelor's preferred).
  • BLS required.
  • 3-5 years clinical experience required.
  • Knowledge of Conditions of Participation for Utilization Review.
  • Demonstration of effective problem-solving techniques, including conflict management skills.
  • Demonstration of excellent oral and written communication skills.
  • Excellent organizational and record-keeping skills, as well as the ability to manage multiple cases.
  • Maintains integrity, confidentiality, and ensures compliance with WRMC's policies and procedures, regulatory and legal requirements, and current healthcare standards.
Essentials:
  • Must be able to report to work fit for duty and free of any adverse effects of illegal drugs, medical marijuana, prescription medication, and/or alcohol.
  • Must be able to effectively communicate both orally and in writing with other individuals.
  • Must be able to work independently, anticipate and organize workflow, prioritize, and follow through on responsibilities.
  • Must be able to skillfully manage a high-volume caseload and respond effectively to rapidly changing priorities.
Physical Demands:

Sitting, standing, walking, and lifting will occur for the majority of the shift. Must be able to lift 20 pounds. Must be able to sit/stand for extended periods of time. Fine motor skills. Visual acuity. Depth perception.



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