The Utilization Review RN is responsible for utilization management and utilization review for prospective, concurrent, or retrospective review.
This position functions as a part of a multidisciplinary team, including physicians, social workers, discharge planning assistants and payers. The Utilization Review RN performs reviews of current inpatient services, and determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
The Utilization Review RN conducts prospective, concurrent and retrospective utilization review for inpatient services, observations, as well as specific outpatient service requests.
Licensure, Certification, or Registration Requirements for Hire:
Licensed Registered Nurse in the State of Virginia or eligible
Licensure, Certification, or Registration Requirements for continued employment:
Current RN licensure in Virginia
Complete 15 Continuing Education Units per year
Minimum of three (3) years of nursing experience in an acute care setting
One (1) year of Care Coordination experience
Clinical experience with specialty patient population
Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc.).
Proficient in Milliman Care Guidelines (MCG) or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Bachelors of Science in Nursing from an accredited School of Nursing
Master’s Degree in Nursing or a healthcare related field from an accredited program
Case Management Certification
Independent action(s) required:
Works with the attending and consulting physicians to facilitate effective and efficient transition through the process of hospitalization.
Works collaboratively with all members of the multi-disciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum, as well as appropriately reimbursed by payers as contracted, and that resources are efficiently and effectively utilized.
Utilizes medical necessity criteria as a tool to assess appropriateness of level and setting of care, assists in the denial and appeals process, assesses quality, and identifies and reports potential risk management issues.
Responsible for participation in and completion of all patient safety initiatives appropriate to the position.
Establishes and maintains a professional rapport with providers, patients/families, and internal customers.
Trains and educates new UM staff nurses and new RN Care Coordinators by demonstrating job competency, providing technical instruction and leadership and generally raising the level of performance of others (within and outside of the department)
Advocates that the patient is placed in the status and level of care for appropriate remuneration of services rendered.
Utilizes clinical application systems with fundamental proficiency in utilization review systems and uses business support applications as needed
Supervisory responsibilities (if applicable): N/A
Additional position requirements:
Ability to flex the schedule as needed to meet the demands of the department
Age Specific groups served: All
Physical Requirements (includes use of assistance devices as appropriate):
Physical Lifting 20-50 lbs.
Activities: Prolonged sitting, Repetitive motion
Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking
Emotional: Fast pace environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Able to adapt to frequent change
Workday Day (United States of America)
EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.