Utilization Review Nurse-Ed; Pt Nights

Overview

Riverside Healthcare is seeking a dedicated and experienced Utilization Review Nurse to join our Emergency Department team in Kankakee, Illinois. The Utilization Review Nurse will play a crucial role in ensuring that patients receive appropriate and effective care while optimizing resource utilization. This position involves reviewing patient cases, assessing the necessity of admissions and continued stays, and collaborating with healthcare providers to enhance patient outcomes and hospital efficiency by managing documentation and optimizing resource utilization.

• Conduct thorough reviews of patient cases in the Emergency Department to assess the necessity and appropriateness of admissions, continued stays, and level of care.
• Utilize clinical knowledge and evidence-based guidelines to make determinations regarding the medical necessity of services.

• Work closely with physicians, nurses, and other healthcare professionals to gather necessary information and discuss care plans.
• Communicate with insurance providers to obtain authorization for treatments and services, ensuring compliance with payer requirements.
• Proactively facilitate throughput of all patients by monitoring for census peaks including surgical and procedural patient placement.

• Maintain accurate and detailed documentation of case reviews, decisions, and communications with healthcare providers and insurance companies.
• Prepare and submit reports as required, including utilization review reports and compliance documentation.

• Participate in quality improvement initiatives to enhance the efficiency and effectiveness of care provided in the Emergency Department.
• Analyze utilization patterns and outcomes to identify opportunities for improvement and contribute to the development of best practices.

• Ensure adherence to hospital policies, payer guidelines, and regulatory requirements related to utilization management.
• Stay informed about changes in healthcare regulations and payer requirements to ensure ongoing compliance.

These are duties that MUST be performed in this job, with or without reasonable accommodation.

• Assist with training and orientation of new staff members on utilization review processes and procedures.
• Support administrative tasks related to the utilization review process as needed.
• Participate in departmental meetings and contribute to discussions on process improvements and policy updates.

• Minimum of 3 years of clinical experience in an Emergency Department setting.

• Prior experience in utilization review or case management is preferred
• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal skills for effective collaboration with healthcare providers and insurance representatives.
• Proficiency in electronic health record (EHR) systems and utilization review software.
• Ability to work independently and manage multiple tasks efficiently in a fast-paced environment.
• Knowledge of Inter Qual and/or MCG and local and national coverage determinations.

• Active Registered Nurse (RN) license in the State of Illinois.
• Associates Degree of Nursing (AND)
• * All new RN;s starting on or after 1/1/25 must complete their Bachelors of Science in Nursing within three years.

• Bachelors Degree in Nursing (BSN) from an accredited institution or higher degree*

Exposure/Sensory Requirements:

• Chemicals:
  Refer to MSDS Sheets
• Video Display Terminals:
  Extreme
• Blood and Body Fluids:
  Minimal potential
• TB or Airborne Pathogens:
  Minimal potential

Sensory requirements (speech, vision, smell, hearing, touch):

• Speech:
  Needed for presentations, training, telephone communication, facilitating meetings.
• Vision:
  Needed for computer entry, reading memos and literature.
• Smell:
  Needed for electrical/fire safety.
• Hearing:
  Needed for telephone communication, meetings and listening to employee concerns.
• Touch:
  Needed for writing, computer entry, filing.

Acti…