Utilization Review RN

Found in: Talent US C2 - 2 weeks ago

Omaha, United States CHI Health Full time
Overview

Utilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and
verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.


Responsibilities
1. Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines toensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews includeadmission, concurrent and post discharge for appropriate status determination.2. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, PeerReview Organization (PRO), Joint Commission, and payer defined criteria for eligibility.3. Reviews the records for the presence of accurate patient status orders and addresses deficiencies withproviders.4. Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholdersregarding review outcomes.5. Collaborates with facility RN Care Coordinators to ensure progression of care.6. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.7. Communicates the need for proper notifications and education in alignment with status changes.8. Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention.9. Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate.10. Establishes and documents a working DRG on each assigned patient at the time of initial review as directed.11. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.12. Responsible for completing required education within established timeframes.13. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.14. Participates regularly in performance improvement teams and programs as necessary.15. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.16. Responsible for completing required education within established timeframes.17. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
Qualifications

Graduate of an accredited school of nursing. RN license in the state(s) covered is required.
Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.

BLS required within 3 months of hiring if located within hospital

Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used.

Preferred

Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification 

Proficient in application of clinical guidelines (MCG/InterQual) preferred

Knowledge of managed care and payer environment preferred.
Must have critical thinking and problem-solving skills.
Collaborate effectively with multiple stakeholders
Professional communication skills.
Understand how utilization management and case management programs integrate.
Ability to work as a team player and assist other members of the team where needed.
Thrive in a fast paced, self-directed environment.
Knowledge of CMS standards and requirements.
Proficient in prioritizing work and delegating where indicated.
Highly organized with excellent time management skills.

  • Utilization Review RN

    Found in: beBee jobs US - 2 weeks ago

    Omaha, Nebraska, United States Catholic Health Initiatives Full time

    OverviewUtilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the...

  • Utilization Review RN

    Found in: beBee S US - 2 weeks ago

    Omaha, United States Catholic Health Initiatives Full time

    Overview Utilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the...

  • UTILIZATION REVIEW RN

    Found in: Careerbuilder One Red US C2 - 2 weeks ago

    Omaha, NE 68102, USA, United States Common Spirit Full time

    OverviewUtilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the...

  • DENIALS MANAGEMENT RN

    Found in: Careerbuilder One Red US C2 - 2 weeks ago

    Omaha, NE 68102, USA, United States Common Spirit Full time

    OverviewThe Denials RN is responsible and accountable for receiving, processing and documenting all concurrent denials for assigned facilities. The RN has an integral role within the revenue cycle by providing clinical expertise in the denials management process.The Denials RN performs a root cause analysis of the concurrent denial, formulates and implements...

  • Staff RN

    Found in: Lensa US P 2 C2 - 4 days ago

    Omaha, United States Omaha Children's Hospital Full time

    $10,000. Hiring Bonus for RNs with 3+ years RN experience Full Time Nights 7:00pm - 7:30 am with weekend rotation We’re searching for a **Staff RN Cardiac Care** to coordinate professional nursing and individualized, family centered care to pediatric patients/families through the use of the nursing process and clinical skills in accordance with standards...

  • Staff RN

    Found in: Lensa US P 2 C2 - 2 weeks ago

    Omaha, United States Omaha Children's Hospital Full time

    Weekends: Fri, Sat, Sun Days or Night Shift Available FT or PT Available Weekend incentive Pay! At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are...

  • Staff RN

    Found in: Lensa US P 2 C2 - 2 weeks ago

    Omaha, United States Children's Hospital & Medical Center Full time

    Job DescriptionWeekends: Fri, Sat, SunDays or Night Shift Available FT or PT AvailableWeekend incentive Pay!At Children's, the region's only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members...

  • Emergency Charge RN

    Found in: Lensa US P 2 C2 - 4 days ago

    Omaha, United States Catholic Health Initiatives Full time

    **Overview** At CHI Health Creighton University Medical Center - Bergan Mercy our focus is patient-centered care. Our level I trauma center and academic medical center campus is designed to heal the body mind and spirit of every person in a more comfortable less stressful hospital environment. Our full range of medical services includes trauma services heart...

  • RN Unit Manager

    7 days ago

    Omaha, United States Emerald Nursing & Rehab Omaha Full time

    Emerald Nursing & Rehab Omaha - Department: Nursing Hourly GENERAL PURPOSE Responsible for the independent supervision of the delivery of care to a group of residents in a Nursing unit under the direction of a DON. ESSENTIAL JOB DUTIES • Develop individualized plan of care in collaboration with the resident or responsible party and interdisciplinary care...

  • Emergency Charge RN

    Found in: Lensa US P 2 C2 - 3 days ago

    Omaha, United States CommonSpirit Health Full time

    Overview: At CHI Health Creighton University Medical Center - Bergan Mercy our focus is patient-centered care. Our level I trauma center and academic medical center campus is designed to heal the body mind and spirit of every person in a more comfortable less stressful hospital environment. Our full range of medical services includes trauma services heart...

  • Travel CVOR Registered Nurse

    Found in: Talent US A C2 - 1 week ago

    Omaha, United States Soliant Full time

    Minimum 1+ years nursing experience required.Travel CVOR Registered Nurse - Omaha, NE "Nursing is not just an art, it has a heart. Nursing is not just a science, but it has a conscience." Are you an adventurous CVOR Registered Nurse (RN) with a passion for travel and a commitment to excellent patient care? Soliant Health is seeking a skilled and dedicated...

  • Emergency Charge RN

    Found in: Resume Library US A2 - 4 days ago

    Omaha, Nebraska, United States CommonSpirit Health Full time

    Overview: At CHI Health Creighton University Medical Center - Bergan Mercy our focus is patient-centered care. Our level I trauma center and academic medical center campus is designed to heal the body mind and spirit of every person in a more comfortable less stressful hospital environment. Our full range of medical services includes trauma services heart...

  • Dialysis Registered Nurse

    2 days ago

    Omaha, United States Dialysis Clinic, Inc. Full time

    Overview Dialysis Clinic, Inc. is recruiting top talent interested in supporting our nonprofit mission to prioritize individualized care for patients facing chronic kidney disease. Our mission states “the care of the patient is our reason for existence,” and our dedicated team embodies our sole purpose during every patient interaction. We seek...

  • Dialysis Registered Nurse

    Found in: Appcast US C2 - 1 week ago

    Omaha, United States Dialysis Clinic, Inc. Full time

    Overview Dialysis Clinic, Inc. is recruiting top talent interested in supporting our nonprofit mission to prioritize individualized care for patients facing chronic kidney disease. Our mission states “the care of the patient is our reason for existence,” and our dedicated team embodies our sole purpose during every patient interaction. We seek...

  • Dialysis Registered Nurse

    Found in: Appcast US C2 - 1 week ago

    Omaha, United States Dialysis Clinic, Inc. Full time

    Overview Dialysis Clinic, Inc. is recruiting top talent interested in supporting our nonprofit mission to prioritize individualized care for patients facing chronic kidney disease. Our mission states “the care of the patient is our reason for existence,” and our dedicated team embodies our sole purpose during every patient interaction. We seek...

  • Associate Director of Nursing

    7 days ago

    Omaha, United States Charles Drew Health Center Full time

    Job Details Job Location: Grant Street - Omaha, NE Salary Range: Undisclosed Description POSITION SUMMARY:Reporting to the Chief Medical Officer, the Director of Nursing (DNO) is responsible for the planning, organizing, directing and financial management of Nursing Services at Charles Drew Health Centers. Requires the independent application of an...

  • Associate Director of Nursing

    1 week ago

    Omaha, United States CareerBuilder Full time

    Job Details Job Location : Grant Street - Omaha, NE Salary Range : Undisclosed Description POSITION SUMMARY: Reporting to the Chief Medical Officer, the Director of Nursing (DNO) is responsible for the planning, organizing, directing and financial management of Nursing Services at Charles Drew Health Centers. Requires the independent application of an...

  • Associate Director of Nursing

    1 week ago

    Omaha, United States Charles Drew Health Center Full time

    Job Details Job Location : Grant Street - Omaha, NE Salary Range : Undisclosed Description POSITION SUMMARY: Reporting to the Chief Medical Officer, the Director of Nursing (DNO) is responsible for the planning, organizing, directing and financial management of Nursing Services at Charles Drew Health Centers. Requires the independent application of an...

  • Paramedic Inpatient

    1 week ago

    Omaha, United States Omaha Children's Hospital Full time

    1900-0730 with weekend and holiday rotation At Children's, the region's only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth...

  • Discover Omaha: Travel Operating Room Registered Nurse

    Found in: Talent US A C2 - 2 weeks ago

    Omaha, United States Soliant Full time

    Minimum 2+ years CVOR Tech experience required.Discover Omaha: Travel Operating Room Registered Nurse - Omaha, NE "Life is a journey, not a destination." - Ralph Waldo Emerson Are you an adventurous Operating Room Registered Nurse with a passion for travel and a commitment to delivering exceptional patient care? Soliant Health is seeking a skilled and...