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Overview

RN Utilization Review Weekender

Job Code: 22818

FLSA Status

Job Family: NURSING

Job Description Title: RN Utilization Review Weekender

Job 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.

Job 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

Specifications

Experience

Description

Minimum Required: RN with 3 years of clinical experience

Preferred/Desired: RN with Case Management or Utilization Review experience in a hospital or payer setting

Education

Description

Minimum Required: Diploma or Associate Degree in Nursing

Preferred/Desired: BSN or MSN

Training

Description

Minimum Required

Preferred/Desired

Special Skills

Description

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

Preferred/Desired

Licensure

Description

Minimum Required: RN

Preferred/Desired: RN;CCM;ACM

Reporting Relationships

Does this position formally supervise employees? If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

Reporting Relationships: No

Work Environment

Functional Demands

Label Short Description Full Description

Sedentary Very light energy level Lift 10lbs. box overhead. Lift and carry 15lbs. Push/pull 20lbs. cart

Light Moderate energy level Lift and carry 25-35lbs. Push/pull 50-100lbs. (ie. empty bed, stretcher)

Medium High energy level Lift and carry 40-50lbs. Push/pull +/- 150-200lbs. (Patient on bed, stretcher) Lateral transfer 150-200lbs. (ie. Patient)

Heavy Very high energy level Lift over 50lbs. Carry 80lbs. a distance of 30 feet. Push/pull > 200lbs. (ie. Patient on bed, stretcher). Lateral transfer or max assist sit to stand transfer.

Functional Demands Rating: Light

Activity Level Throughout Workday

Physical Activity Requirements – Sitting: Frequent

Physical Activity Requirements – Standing: Occasional

Physical Activity Requirements – Walking: Occasional

Physical Activity Requirements - Climbing (e.g., stairs or ladders): Occasional

Physical Activity Requirements - Carry objects: Occasional

Physical Activity Requirements - Push/Pull: Occasional

Physical Activity Requirements – Twisting: Occasional

Physical Activity Requirements – Bending: Occasional

Physical Activity Requirements - Reaching Forward: Occasional

Physical Activity Requirements - Reaching Overhead: Occasional

Physical Activity Requirements - Squat/Kneel/Crawl: Occasional

Physical Activity Requirements - Wrist position deviation: Occasional

Physical Activity Requirements - Pinching/fine motor activities: Frequent

Physical Activity Requirements - Keyboard use/repetitive motion: Continuous

Physical Activity Requirements - Taste or smell

Physical Activity Requirements - Talk or hear: Frequent

Sensory Requirements

Color Discrimination: Yes

Near Vision: Very Accurate

Far Vision: Accurate

Depth Perception: Minimal

Hearing: Minimal

Environmental Requirements - Blood-Borne Pathogens: Anticipated

Environmental Requirements – Chemical: Anticipated

Environmental Requirements - Airborne Communicable Diseases: Anticipated

Environmental Requirements - Extreme Temperatures: Not Anticipated

Environmental Requirements – Radiation: Not Anticipated

Environmental Requirements - Uneven Surfaces or Elevations: Not Anticipated

Environmental Requirements - Extreme Noise Levels: Not Anticipated

Environmental Requirements - Dust/Particular Matter: Not Anticipated

Environmental Requirements - Other

REQNUMBER: 31011