Summary
The Utilization Review Nurse RN collaborates with the physician and members of the multidisciplinary team to facilitate progression-of-care;
monitors the patient's progress, intervening appropriately to ensure that the plan of care and services provided are patient focused, high quality, evidence based, appropriate to patient needs, efficient, and cost effective.
Conduct concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, accrediting bodies, and other state agencies.
Prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines and insurance benefits and communicates information to payers in accordance with contractual obligations.
Serve as a resource to the physicians and provide education and information on resource utilization, national and local coverage determinations, and use of hospital admission criteria.
Job Requirements
- Education Required : Graduate of an accredited school of nursing Preferred : Bachelor's of Nursing with knowledge of InterQual Level of Care Criteria and / or Milliman Care Guidelines and of local / national coverage determinations
- Experience Required : Minimum of 3 years hospital experience
- Skills Excellent interpersonal skills, including ability to be genuine and empathetic Excellent communication (verbal and written) skills with attention to detail Computer skills Ability to interact professionally and contribute to the interdisciplinary team
- Licensure / Certification / Registration Current RN License active in the state of Missouri Preferred : Certified Case Manager
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