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RN Utilization Review Specialist

2 months ago

Scottsdale, Arizona, United States HonorHealth Full time
Job Summary

The Utilization Review RN Specialist plays a critical role in ensuring high-quality, cost-effective care for patients at HonorHealth. This position is responsible for reviewing and monitoring the utilization of healthcare services to maintain optimal care levels.

Key Responsibilities:
  • Medical Necessity Reviews: Conduct comprehensive reviews of clinical documentation to ensure accuracy and compliance with government regulations. Perform initial and concurrent reviews on all patients entering the healthcare continuum.
  • Resource Utilization: Facilitate the delivery of services to patients and families through effective utilization of available resources. Collaborate with physicians, case managers, and payers to appeal individual denials and trended issues related to contract guidelines.
  • Documentation and Reporting: Work with medical records, finance, and physician groups to develop systems for complete documentation and data reporting. Maintain a system to identify admissions with specific diagnosis/DRG classifications or other categories of admissions.
  • Communication and Collaboration: Notify attending physicians and house staff of documentation issues requiring clarification. Determine qualifications for hospital level of care based on set criteria.
Requirements:
  • Associate's Degree in Nursing from an accredited NLN/CCNE institution
  • 3 years Registered Nurse experience in an acute care setting
  • 1 year experience in UR/UM or Case Management
  • Registered Nurse (RN) State And/Or Compact State Licensure
Work Environment:

This position is located in a dynamic healthcare environment, working closely with multidisciplinary teams to deliver high-quality patient care. The ideal candidate will possess excellent communication and collaboration skills, with a strong focus on patient-centered care.