Job detail

Utilization Review Nurse RN or LPN

Unity Health

#RN #LPN #Healthcare Administration #CMS #Patient Acuity #Medical Staff Coordination #Utilization Review #CPT Coding #Concurrent Review

Quick overview

The role focuses on coordinating utilization management and denial prevention to ensure patients receive the right care at the right cost and setting. Responsibilities include reviewing clinical practices and maintaining a quality control system to optimize hospital facility usage.

Requirements summary

Candidates must hold a current Arkansas RN license and possess strong clinical knowledge, preferably with experience in ICD-CM and CPT coding. The position requires the ability to communicate effectively with medical staff and apply nursing knowledge to determine patient acuity levels.

professional certificateCase ManagementPatient Care CoordinationCPT CodingUtilization ReviewMedical Staff CommunicationDenial PreventionNursing KnowledgeICD-CM CodingClinical Chart ReviewAcuity Level Determination

Job description

Education

Should have a high level of clinical knowledge and a current Arkansas licensure as a RN. Preferably experienced in the use of ICD-CM and CPT coding systems. Skilled in the use of the computer and photocopier. Good people and phone skills required.

2. Training and Experience

Should have past experience working with Medical Staff, patients, hospital associates and insurance companies. Must be capable of following verbal and written instructions. Should practice diplomacy in dealing with Medical Staff, patients, associates and insurance companies. Will participate in ongoing education through workshops, in service programs and updates from CMS, AFMC and other government and private agencies.

3. Job Knowledge

Must be able to communicate verbally and in written format with the Medical Staff, review organizations, administration and others as indicated. Must be able to apply current nursing knowledge to determine appropriate acuity levels and appropriate care by chart review.

4. Safety Sensitive: NO

In the interest of protecting the health and safety of all patients, associates, and guests, Unity Health has classified some positions as “safety sensitive.” A “safety sensitive” position is any job position in which impaired performance could result in harm to the health and/or safety of self or others. Any associate that is actively engaged in the use of medical marijuana, even if in possession of a valid medical marijuana card, will be excluded from employment in a “safety sensitive” position.

Description

Should have the ability to work under pressure and in conditions of frequent interruptions.
He/she needs considerable initiative and judgment while performing duties in an area where procedures are standardized but where frequent independent decisions are required.
Help maintain a quality control system to assure effective utilization of hospital facilities and services.
Assist in the promotion and maintenance of high quality care through review of clinical practices within the hospital based on pre-established criteria.
The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, and promoting clinical best practice.
Ensuring all patients receive “the right care, the right cost, right time, and in the right setting.” This position requires knowledge in the care of patients served as indicated: Infant to adolescence is 0 to 17 years, Adult is 18 years to 65 years and Geriatric is 65 years and above.

Physical Effort

Sits at desk when he/she is not locating records and other various information for nurses, doctors, etc. or is on the nursing stations performing concurrent review. Works in a well-lighted, air conditioned office.