Clinical Utilization Review Nurse
3 weeks ago
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.
- 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.
- 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.
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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