Utilization Review Nurse
: Job Details :

Job Summary The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. He/she actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. This individual maintains current and accurate knowledge regarding commercial and government payers and CIHQ regulations/guidelines/criteria related to UM. The UR Nurse effectively and efficiently manages a diverse workload in a dynamic regulatory environment. The UR Nurse is a member of, and provides support to, the hospital's UR Committee. He/she collaborates with multiple leaders at various levels throughout Shannon Health, for the purpose of supporting and improving the UM program. Education Education Type Program of Study Required/Preferred High School Diploma N/A Required Associate's degree Nursing Required Bachelor's degree Nursing Preferred Experience Number of Years Type of Experience Required/Preferred 5 Years Clinical nursing Required 1 Year Inpatient Utilization Review Preferred Certification & Licensures Certification/Licensure Type Required/Preferred Registered Nurse (RN), with Authorization to Practice in the State of Texas Required ACM (Accredited Case Manager) through ACMA Preferred CCM (Certified Case Manager) through CCMC Preferred *Must obtain within ninety (90) days of hire