Job SummaryWe are looking for a compassionate and detail-oriented Registered Nurse (RN) to join our Utilization Review team. The RN will be responsible for evaluating and ensuring the appropriate utilization of healthcare services for patients, based on medical necessity, clinical guidelines, and insurance requirements. This role involves collaborating with healthcare providers, insurance companies, and patients to ensure that patients receive the appropriate care while adhering to established medical standards and regulations.
Key Responsibilities- Conduct comprehensive reviews of patient medical records and treatment plans to determine the appropriateness of services provided.
- Evaluate the medical necessity of inpatient, outpatient, and surgical services, ensuring compliance with insurance guidelines and industry standards.
- Collaborate with physicians, care teams, and insurance representatives to discuss case management decisions, ensure continuity of care, and resolve disputes.
- Communicate with patients and families to explain treatment plans, address concerns, and ensure understanding of care options.
- Utilize clinical criteria and guidelines (e.g., Milliman Care Guidelines, InterQual) to support decision-making and ensure the most efficient use of healthcare resources.
- Document all utilization review activities, including approvals, denials, and recommendations, in accordance with regulatory and organizational standards.
- Participate in case conferences, audits, and quality improvement initiatives to ensure the highest standards of care are maintained.
- Ensure compliance with all relevant laws, regulations, and healthcare policies, including HIPAA and accreditation standards.
- Provide education and guidance to staff, patients, and families regarding healthcare options, resources, and best practices for care management.
Required Qualifications- Current, unrestricted RN license in the state of practice.
- Minimum of 3 years of clinical nursing experience, with a strong background in medical-surgical nursing, case management, or utilization review.
- In-depth knowledge of clinical guidelines, insurance protocols, and healthcare regulations.
- Strong critical thinking and analytical skills to evaluate clinical data and make informed decisions.
- Excellent communication and interpersonal skills, with the ability to interact effectively with healthcare providers, insurance companies, and patients.
- Ability to manage multiple priorities and work independently with minimal supervision.
Preferred Qualifications- Certification in Utilization Review (e.g., Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM)).
- Previous experience working with insurance companies or health plans in utilization management.
- Experience with electronic health records (EHR) systems and utilization review software.
Certifications (if any)- Certified Professional in Utilization Review (CPUR) or Certified Case Manager (CCM) preferred.
- BLS (Basic Life Support) certification required
Location-1823 College Avenue, Manhattan, KS, 66502
Certification: Certified Case Manager , Basic Life Support , Certified Professional in Utilization Review