Claims Utilization RN

Job Description

Job Description

Description

The Utilization Review / Management (UR / UM) Nurse position will work in in our UR / UM department.  An overview of the work includes assessing patient care to ensure it is medically necessary, cost-effective, and compliant with clinical guidelines and regulatory requirements. Key duties include reviewing patient records and pre-certification requests, communicating with providers, and advocating for appropriate, evidence-based, and efficient patient care across the healthcare journey. The role requires strong analytical, documentation, and communication skills.

Key Responsibilities

• Medical Necessity Review : Assess patient records and treatment plans to determine the medical necessity and appropriateness of services, ensuring patients are only receiving care that cannot be provided in the jail.
• Pre-certification / Pre-authorization : Review requests for medical services to ensure they meet guidelines before treatment is provided.
• Concurrent Review : Evaluate ongoing patient care and length of stay to ensure it aligns with expected standards, working to return the patient to the jail as soon as the patient can be cared for by jail medical staff.
• Retrospective Review : Conduct post-service reviews to assess the overall appropriateness and efficiency of care. Work with hospitals and offsite providers to adjust overbilling, incorrect billing and unneeded services.
• Communication : Liaise with healthcare teams to coordinate care.  Address provider appeals when we deny payment for a service.
• Compliance : Ensure that patient care adheres to clinical guidelines, healthcare standards, jail medical staff direction and regulatory requirements.
• Cost-Effectiveness : Advocate for quality evidence-based care while minimizing unnecessary costs and resource waste, with the goal to get patients back to the jail as soon as medically appropriate.
• Reporting : Track, evaluate, and report on UR / UM program metrics and outcomes.
• Process Improvement : Participate in initiatives to improve healthcare processes and patient outcomes.

Skills, Knowledge and Expertise

Skills & Qualifications