Job Summary
The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination.
This individual supports the UM program by developing and / or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers.
This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported.
This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
He / she actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.
This individual maintains current and accurate knowledge regarding commercial and government payers and CIHQ regulations / guidelines / criteria related to UM.
The UR Nurse effectively and efficiently manages a diverse workload in a dynamic regulatory environment. The UR Nurse is a member of, and provides support to, the hospital's UR Committee.
He / she collaborates with multiple leaders at various levels throughout Shannon Health, for the purpose of supporting and improving the UM program.
Education
Education Type
Program of Study
Required / Preferred
High School Diploma
N / A
Required
Associate's degree
Nursing
Required
Bachelor's degree
Nursing
Preferred
Experience
Number of Years
Type of Experience
Required / Preferred
5 Years
Clinical nursing
Required
1 Year
Inpatient Utilization Review
Preferred
Certification & Licensures
Certification / Licensure Type
Required / Preferred
Registered Nurse (RN),
with Authorization to Practice in the State of Texas
Required
ACM (Accredited Case Manager) through ACMA
Preferred
CCM (Certified Case Manager) through CCMC
Preferred
- Must obtain within ninety (90) days of hire
Utilization Review Nurse
The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring tha...
Utilization Review Nurse
The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring tha...
Utilization Review Nurse
The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring tha...
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