Job Summary The Utilization Review Nurse is responsible for ensuring that patients receive appropriate, cost-effective care by reviewing medical records, treatment plans, and healthcare services. The role involves collaborating with healthcare providers and an interdisciplinary team to optimize resource utilization and improve patient outcomes. The Utilization Review Nurse ensures parties follow The Joint Commission standards, authorizations and medical necessity, fiscal stability through denials review, and monitors Length of Stay efforts of the Hospital.
Essential Functions Conduct detailed reviews of patient medical records to ensure treatments and services meet established guidelines and criteria.
Assess the appropriateness of proposed treatment plans and recommend modifications to enhance patient care and resource efficiency.
Assists with the denials process with focus on clinical reviews, peer-to peer reviews, payer communications, tracking and other duties related to denials and denials prevention.
Complete all inpatient admission and observation reviews for all inpatient units, with priority to observation cases and denied inpatient admissions with commercial insurance.
Provide education and support to healthcare staff regarding utilization review processes, best practices, and regulatory requirements.
Participate in quality improvement initiatives, contributing to the development and implementation of utilization review policies and procedures.
Maintain comprehensive and accurate documentation of all reviews, authorizations, and communications with healthcare providers and insurance companies.
Assists the Director of Quality with developing specific departmental goals, standards, and objectives which directly support the strategic plan and vision of the organization as requested
Other duties as assigned.
Functional/Technical Skills Requirements Comprehensive understanding of operational health care delivery systems and the current health care landscape. Skills and experience with developing competitive business strategies for health care and operational aspects of health care technology deployment. Familiarity and comfort with technology-based operational improvement.
Communications: Excellent written and verbal communications skills. Ability to take abstract, complex and/or technical information and effectively convey the message for a variety of audiences at their level of comprehension.
Functional Oversight: Issue identification, gap analysis, ability to prioritize business needs and execute solutions.
Technology: Proficient in use of health care technology. Skilled in technology-based operational improvement: auditing, data aggregation, monitoring.
Minimum Education/Certification Knowledge of New Jersey and national quality management and regulatory standards, including reporting.
Bachelor's degree in Nursing, Healthcare Administration, or a related field
Current RN license or equivalent clinical certification
Preferred Education/Certification Certification in CPUR, HCQM, or CPHQ
Master's degree in healthcare
Minimum Work Experience Required 1 year of experience in quality improvement and/or utilization review in an acute care setting.
Minimum of 2 years of related experience in utilization review, case management, or related field.