Registered Nurse; RN - Utilization Management Review - Days- Remote

Overview

The Utilization Review RN oversees utilization management and review for prospective, concurrent, and retrospective services within a multidisciplinary team, including physicians, social workers, discharge planning assistants, and payers. The RN assesses medical appropriateness of inpatient and outpatient services following medical guidelines and benefit determination.

• Conduct prospective, concurrent, and retrospective utilization review for inpatient services, observations, and specific outpatient service requests.
• Collaborate with attending and consulting physicians to facilitate efficient transition through hospitalization process.
• Work collaboratively with all members of the multidisciplinary team to coordinate patient needs across the continuum and ensure appropriate reimbursement by payers.
• Utilize medical necessity criteria to assess appropriateness of level and setting of care, assist in denial and appeals process, assess quality, and report potential risk management issues.
• Participate in and complete all patient safety initiatives appropriate to the position.
• Establish and maintain a professional rapport with providers, patients/families, and internal customers.
• Train and educate new UM staff nurses and new RN Care Coordinators by demonstrating job competency, providing technical instruction and leadership.
• Advocate placement of the patient in the appropriate status and level of care for appropriate remuneration of services rendered.
• Utilize clinical application systems with fundamental proficiency in utilization review systems and use business support applications as needed.

• Licensed Registered Nurse in the State of Virginia or eligible.
• Current RN licensure in Virginia.
• Complete 15 Continuing Education Units per year.
• Case Management Certification (preferred).

• Minimum of three (3) years of nursing experience in an acute care setting.
• One (1) year of Care Coordination experience (preferred).
• Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or managed care organization (HMO/TPA/IPA/etc.) (preferred).
• Proficient in Milliman Care Guidelines (MCG) or Inter Qual criteria for medical necessity, setting and level of care, and concurrent patient management.

• Bachelor of Science in Nursing from an accredited School of Nursing (required).
• Master's Degree in Nursing or healthcare related field from an accredited program (preferred).

• Ability to flex the schedule as needed to meet the demands of the department.
• Physical lifting 20-50 lbs.
• Prolonged sitting, repetitive motion, strong recall, reasoning, problem solving, hearing, speak clearly, write legibly, reading, logical thinking.

EEO:
Employer/Disabled/Protected Veteran/41 CFR 60-1.4.