Utilization Review Registered Nurse Specialist
Job SummaryConducts admission, concurrent and retrospective reviews of patients in accordance with hospital objectives and works with the medical staff to assure high quality patient care with effective, efficient utilization of health services.
Minimum QualificationsMinimum QualificationsBachelor's degree in Nursing.
Current Maryland RN license or license eligible.
Three years of clinical experience in a related area.
Preferred QualificationsKnowledge of Milliman & Robertson and Interqual criteria preferred.
UR experience preferred.
Department Specific QualificationsPrimary Duties and ResponsibilitiesContributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards.
Complies with governmental and accreditation regulations.
Conduct admission, concurrent and retrospective reviews of patients in accordance with Hospital objectives and work with the medical staff to assure high quality patient care with effective, efficient utilization of health services.
Maintain accurate and concise documentation of all review activities.
Maintain current, comprehensive knowledge of State and Federal regulatory requirements regarding Utilization Review (UR), and report identified or suspected problems.
Routinely communicate with external review agents regarding appropriateness of admission and necessity of continued hospital stay using recognized evidence based criteria.
Conduct reviews via telephone with contracted third party payors, physician medical advisors, and other appropriate sources regarding medical information necessary for certification of need for hospital care.
Continuously communicate with the Case Manager and Social Worker concerning cases which may not meet acute care criteria, potential discharge planning problems, and other pertinent information as needed, such as problems in the quality of care as related to documentation, treatment modalities, timely completion and reporting of testing and validity of the admission/working diagnosis.
Notify patients of potential insurance denials and when there is a change in status from inpatient to outpatient observation.
Maintain accurate and concise documentation of all review activities.
Conducts status reviews to ensure patient meets inpatient verses outpatient criteria and ensures registration to the same.
Performs other duties as assigned.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
Minimum QualificationsMinimum QualificationsBachelor's degree in Nursing.
Current Maryland RN license or license eligible.
Three years of clinical experience in a related area.
Preferred QualificationsKnowledge of Milliman & Robertson and Interqual criteria preferred.
UR experience preferred.
Department Specific QualificationsPrimary Duties and ResponsibilitiesContributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards.
Complies with governmental and accreditation regulations.
Conduct admission, concurrent and retrospective reviews of patients in accordance with Hospital objectives and work with the medical staff to assure high quality patient care with effective, efficient utilization of health services.
Maintain accurate and concise documentation of all review activities.
Maintain current, comprehensive knowledge of State and Federal regulatory requirements regarding Utilization Review (UR), and report identified or suspected problems.
Routinely communicate with external review agents regarding appropriateness of admission and necessity of continued hospital stay using recognized evidence based criteria.
Conduct reviews via telephone with contracted third party payors, physician medical advisors, and other appropriate sources regarding medical information necessary for certification of need for hospital care.
Continuously communicate with the Case Manager and Social Worker concerning cases which may not meet acute care criteria, potential discharge planning problems, and other pertinent information as needed, such as problems in the quality of care as related to documentation, treatment modalities, timely completion and reporting of testing and validity of the admission/working diagnosis.
Notify patients of potential insurance denials and when there is a change in status from inpatient to outpatient observation.
Maintain accurate and concise documentation of all review activities.
Conducts status reviews to ensure patient meets inpatient verses outpatient criteria and ensures registration to the same.
Performs other duties as assigned.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
|
|
 | |
