RN-Utilization Review Job Description
Rn-utilization review
provides first level clinical review for all inpatient and outpatient services requiring authorization for assigned client group regarding: Retrospective Review.
RN-Utilization Review Duties & Responsibilities
To write an effective rn-utilization review job description, begin by listing detailed duties, responsibilities and expectations. We have included rn-utilization review job description templates that you can modify and use.
Sample responsibilities for this position include:
Process the information and determine necessity of the hospital days using standardized criteria
Type or cut and paste the information into the members inpatient case
Interact with a physician if necessary
Help members make the best decisions for their care and support them through major health issues and transitions, using clinical experience and knowledge of the company’s benefits, network, and resources
Use the company's tools and processes to perform and track member care-related engagement
Manage workload of inbound and outbound support needs efficiently
Develop insights from daily work to help improve the company's ’s processes, member/provider experience, and how the company identifies members who would benefit from care support
Maintain continued professional growth and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice
Determine the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines
Interact with providers, members, and internal service teams to obtain necessary information and communicate approval determinations
RN-Utilization Review Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for RN-Utilization Review
List any licenses or certifications required by the position: CCM, ACM, BLS, OASIS, ICD, CPR, LPN, RN, TCM, CM
Education for RN-Utilization Review
Typically a job would require a certain level of education.
Employers hiring for the rn-utilization review job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Health, Graduate, Management, Healthcare, School of Nursing, Associates, Science, Nursing Program
Skills for RN-Utilization Review
Desired skills for rn-utilization review include:
Medicare
Insurance industry and claims processing
HIPPA and NCQA standards
Health Services policies and procedures
Medical coding
Regulatory requirements
Authorization changes
Care management
Contract changes
Utilization review changes
Desired experience for rn-utilization review includes:
Experience conducting reviews for medical necessity
This role is considered patient facing
Experience in utilization management or reviewing criteria for placement and appropriateness of services
Graduate from an accredited School of Nursing, Associate's or Bachelor's Degree in Nursing, or Bachelor's Degree in an appropriate related field
Knowledge of members' benefits in order to work collaboratively with internal and external healthcare
Active RN license in Texas or Compact State License
RN-Utilization Review Examples
1
RN-Utilization Review Job Description
Job Description Example
Our growing company is hiring for a rn-utilization review. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for rn-utilization review
- Assuring case mix index, Diagnostic Related Group (DRG) assignment and severity/mortality profiles are accurate by reviewing up-to-date reports
- Developing concurrent educational programs for physicians and other clinical staff to improve adherence to proper documentation
- Improve medical record physician documentation by performing concurrent medical record reviews and addressing incomplete documentation with direct interaction with Physicians
- Indirectly assuring case mix index, Diagnostic Related Group (DRG) assignment and severity/mortality profiles are accurate by reviewing up-to-date reports
- Meet required decision-making timeframes
- Clearly document all communication and decision-making within utilization review tracking platform
- Demonstrate the highest level of professionalism, accountability, and service
- Learn and use tools and processes to perform and properly track all utilization reviews
- Ensure information related to utilization management is received from hospitals, nursing facilities, medical providers and other health care entities
- Promote improved quality of care and/or life
Qualifications for rn-utilization review
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab strongly preferred
- Prevent hospitalization/readmission when possible and appropriate
- Prevent complications in patients by assuring discharge planning and transition of care continuity is in place and implemented for
- Collect relevant medical information and apply the appropriate evidence-based guidelines and medical policy
- Clearly document all communication and decision-making within our utilization review tracking platform
- Demonstrate the highest level of professionalism, accountability, and service in your interactions with teammates, customer service, providers, and members
2
RN-Utilization Review Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of rn-utilization review. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for rn-utilization review
- Acts as a liaison with the RN Care Coordinators and Care Coordination Social Workers to facilitate the appropriate utilization of hospital resources and timely discharge
- Reviewing, monitoring and documenting admission and continued stay reviews for all payors using Milliman Care Guidelines and the center’s Utilization Review Plan
- Working on admissions
- Obtaining determinations from insurance companies
- Making appeal recommendations
- Assist with discharge planning efforts
- Facilitating the continuum of care
- Timely discharge
- Provide clear and accurate information to insurance representatives, MD offices and Case Managers
- Promote and maintain collaborative working relationships
Qualifications for rn-utilization review
- Ability to adapt in a dynamic work envioronment while maintaining relationships with external staff members
- Demonstrated knowledge of diagnostic codes
- If selected for this role, a TB screen is required
- May act as an educational resource and provides consultation to hospital medical personnel regarding discharge planning process and applicable federal, state and local regulations
- Minimum 5 years of clinical nursing experience in an acute care hospital setting required
- Complete medical review and interpretation of medical record to obtain authorization of care and services
3
RN-Utilization Review Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of rn-utilization review. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for rn-utilization review
- Oversees the coordination and delivery of comprehensive, quality healthcare and services for all members requiring care management in a cost-effective manner
- Ensuring information related to utilization management is received from hospitals, nursing facilities, medical providers and other healthcare entities
- Promoting improved quality of care and/or life
- Preventing hospitalization / readmission when possible and appropriate
- Preventing complications in patients by assuring discharge planning and transition of care continuity is in place and implemented for
- Responsible for utilization review and discharge planning for capitated patients who are hospitalized
- The review includes coordination of services for medical necessity, cost effectiveness, timelines of service and ensuring that quality standards are met
- Performs coordination of services for patients whose health plan has an at-risk agreement to ensure that services are medically necessary, cost effective, provided in a timely manner and meet local standards or care
- Responsible for prospective, concurrent review and retrospective review authorizations and ongoing management for outpatient/inpatient medical, home health care and skilled nursing facilities
- Responsible for reviewing and making timely coverage recommendations based on medical appropriateness, for all products, while maintaining the integrity of each product line
Qualifications for rn-utilization review
- Utilization Review experience, or reviews for medical necessity, in a managed care, home health or hospital setting
- Ability to work in a dynamic environment while maintaining a consistent professional demeanor
- Active Compact RN license in MS
- Subject for travel based on client needs
- Knowledge of Milliman or Interqual criteria preferred
- Prior supervisory experience with direct reports
4
RN-Utilization Review Job Description
Job Description Example
Our company is growing rapidly and is looking to fill the role of rn-utilization review. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for rn-utilization review
- Responsible for applying clinical skills and expertise in conjunction with established medical criteria, members’ eligibility and benefit coverage information, in the review of prior authorization requests, to ensure high quality, cost effective care
- Serves as subject matter expert on complex medical management issues for internal and external customers
- Pursues Physician Advisor services when treatment plan requests do not meet evidenced-based criteria
- Channels certified treatment plan requests to preferred vendors as necessary
- Maintains a score of 90% or higher on monthly internal utilization review audits
- Complete medical necessity review of charts
- Communicate with insurance companies when indicated to provide clinical reviews to obtain authorization for hospital stays
- Refer cases not meeting InterQual/Milliman criteria to Physician Advisor for evaluation and follow through with recommendations
- Consult with the physician whenever admission or continued stay does not meet approved criteria and cannot justify the admission or continuation of hospitalization
- Monitor and complete cases as identified on initial, concurrent and discharged review work queue
Qualifications for rn-utilization review
- One year of experience in Utilization Review preferred
- Weekend/Holiday Rotation Required
- Graduate of an accredited Registered Nursing Program, Bachelor Degree preferred
- Minimum of three years diverse clinical experience as RN
- Minimum of two years case management and/or utilization review experience
- Strong clinical practice knowledge
5
RN-Utilization Review Job Description
Job Description Example
Our company is looking for a rn-utilization review. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for rn-utilization review
- Actively communicate with and assist Case Managers
- Support compliance with HFAP, State, and Federal Agencies for assigned areas
- Keep abreast of current trends in Utilization Review and Managed Care processes
- Maintain accurate, concise, and timely documentation in Epic
- Work collaboratively with the multiple disciplines, both internal and external to the organization, in effecting quality and cost-effective management of the patient care along the continuum
- Conduct pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts
- Facilitate member care transition through the healthcare continuum and refer treatment plans / plan of care to Clinical Reviewers as required and does not issue non-certifications
- Maintains a collaborative working relationship with the payor's utilization review nurses and case managers and maintains contact with the payor regarding initial assessment, progress, changes in condition, discharge planning, discharge date, as needed
- Demonstrates performance consisten with professional standards of practice, care, performance, the Nurse Practice Act
- Coordination of services for medical necessity, cost effectiveness, timelines of service and ensuring that quality standards are met
Qualifications for rn-utilization review
- CCM or Utilization Review/Management certification
- Working knowledge with INTERQUAL or Milliman
- Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers
- Basic proficiency with MS Office, Word and Excel
- Must have strong PC skills with current operating systems
- Must have outstanding telephonic and personable skills to communicate with various entities, ( ie