RN-Utilization Review

Summary

The Utilization Review Nurse is responsible for evaluating the medical necessity and appropriateness of healthcare services and treatment as prescribed by utilization review standards. The UR Nurse works with providers, insurance companies and patients to ensure cost-effective and appropriate care. Areas of work include status management, medical necessity reviews, verification of authorization, resource utilization, and denial prevention.

Responsibilities

• Completes and enters inpatient and observation admission review against standard criteria per payer guidelines
• Prioritizes observation case review
• Assists with level of care in collaboration with attending provider
• Enters working diagnosis-related groups (DRGs) in the electronic medical record
• Submits clinical information to payer per payer requirements
• Completes continued stay reviews every 3 days or more often if required
• Communicates with care coordinators for authorized days, level of care, medical necessity or other areas when indicated
• Communicates with physician advisors related to status concerns or denials
• Updates auth / cert screen in the electronic medical record
• Works assigned queues in the electronic medical record
• Communicates with authorization coordinator
• Communicates in-house high dollar case information

Completes assigned goals

Requirements, Preferences and Experience

Experience Minimum :

RN with 3 years of clinical experience

Experience Preferred :

RN with 3 years of clinical experience

Education Minimum :

Diploma or Associate Degree in Nursing

Education Preferred :

BSN or MSN

Special Skills Minimum :

Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills. Problem solving; and knowledge of governmental regulations.

Licensure Minimum : RN

Licensure Preferred :

CCM;ACM

About Baptist Memorial Health Care

At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry-healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey.

At Baptist, We Offer :

Job Summary :

Position : 19737 - RN-Utilization Review

Facility : BMHCC Corporate Office

Department : HS Case Mgmt Administration Corporate

Category : Nurse RN

Type : Clinical

Work Type : PRN

Work Schedule : Days

Location : US : TN : Memphis

Located in the Memphis metro area