We are seeking a detail-oriented and knowledgeable Utilization Review Nurse to join our healthcare team. The ideal candidate will possess extensive clinical experience, including inpatient and outpatient settings, with a focus on utilization management, medical documentation review, and compliance with healthcare regulations. This role involves evaluating patient care plans to ensure appropriate utilization of resources while maintaining quality standards and regulatory adherence.
The Utilization Review RN is responsible for ensuring appropriate patient status determination, medical necessity review, regulatory compliance, payer authorization management, denial prevention, and revenue integrity. The Utilization Review RN collaborates with physicians, physician advisors, case managers, social workers, and payers to ensure patients receive care in the appropriate setting while optimizing reimbursement and maintaining compliance with CMS, Joint Commission, and payer requirements. The Utilization Review RN actively participates in throughput initiatives, length-of-stay management, observation reduction strategies, denial mitigation efforts, and clinical documentation improvement processes.
Required Education:
- Graduate of an accredited School of Nursing.
- Current unrestricted Illinois Registered Nurse (RN) license.
- Bachelor of Science in Nursing (BSN) preferred; required within 2 years of hire if not currently obtained.
- Current knowledge of CMS Conditions of Participation, Medicare regulations, and payer requirements.
Desirable Education:
- Bachelor’s degree in Nursing
Required Experience:
- Minimum two (2) years acute care clinical nursing experience
- Minimum two (2) years Utilization Management, Utilization Review, Case Management, Revenue Cycle, or Care Coordination experience
- Experience with InterQual and/or MCG (Milliman) criteria
- Experience working with Medicare, Medicaid, Managed Medicare, Commercial, and Managed Care payers
Desirable Experience:
- Minimum of three (3) years of Utilization Review experience in a health care setting.
Preferred Certifications:
- Accredited Case Manager (ACM)
- Certified Case Manager (CCM)
- Certified Professional in Utilization Management (CPUM)
- Certification in Healthcare Quality or Revenue Cycle
Duties & Responsibilities:
- Perform admission review for inpatient stays and 23-Hour Observation utilizing InterQual Criteria and assigning an initial LOS, if case meets criteria.
- Provide third party payers the necessary information to secure hospital reimbursement and timely transfer.
- Collaborate with the physician advisor regarding all cases that do not meet criteria. Escalate cases that fail medical necessity criteria to the Physician Advisor for secondary review.
- Collect and record medical and other data needed to document a current review.
- Obtain patient information in order to assess the needs of the patient and ensure a safe, timely, and cost-effective discharge.
- Identify potential quality issues and presents material to appropriate medical staff and/or advise Director of Clinical Case Management to send case information to the Utilization Review Committee for recommendation of action.
- Identify areas of over or under utilization and referrals to the appropriate persons.
- Assess patient needs based on age and individual development and shares information with the Discharge Planning Team.
- Work with the Social Worker and attending physician to provide appropriate referrals for continuing care after hospitalization (i.e. home health services, durable medical equipment, and community support).
- Identify needs for alternative care setting (i.e. nursing home, sub acute, psychiatric, intermediate care facility) to collaborate with the Social Worker to arrange placement in a timely manner.
- Document all admissions and concurrent clinical information, as well as interventions, delays, and secondary review requests in EMR utilization record.
- Document all communication with third party payers on the Utilization Review Communication Sheet to ensure professional staff and physicians are informed about potential issues for approval of hospital stay and restrictions on referral Utilization to ensure continuity of care.
- Assist the Utilization Review Committee by collecting and compiling data.
- Prepare and complete statistical and narrative reports.
- Ensure compliance with the CMS Two-Midnight Rule.
- Escalate cases that fail medical necessity criteria to the Physician Advisor for secondary review.
- Facilitate peer-to-peer reviews when required by payers.
- Monitor observation patients daily and identify opportunities for status conversion or discharge.
- Authorization and Reimbursement Management
Pay: $88,000.00 - $123,000.00 per year
Benefits:
- 403(b)
- Dental insurance
- Employee assistance program
- Free parking
- Health insurance
- Health savings account
- Paid time off
- Tuition reimbursement
- Vision insurance
Work Location: In person
