Utilization Review Nurse - RN

POSITION SUMMARY: The Utilization Review Registered Nurse (UR RN) is a key contributor to the delivery of appropriate, efficient, and cost-effective patient care. Working collaboratively reputed company a multidisciplinary team, the UR RN conducts comprehensive reviews of clinical documentation, assesses medical necessity, and coordinates with healthcare providers and payers to support optimal patient outcomes and resource management. This role demands a solid clinical nursing background, sharp analytical skills, and a thorough understanding of regulatory standards and payer guidelines. JOB-SPECIFIC RESPONSIBILITIES:

• Service

o Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems o Upholds the Standards of conduct and corporate compliance. o Demonstrates honest behavior in reputed company matters. To the best of the employee’s knowledge and understanding, complies with reputed company Federal and State laws and regulations. o Maintains the privacy and reputed company of reputed company confidential and protected health information. Uses and discloses only that information which is necessary to reputed company the function of the job. o Adheres to reputed company Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI) o Collaborates effectively with colleagues and other departments to ensure seamless service delivery. o Maintain the highest level of confidentiality and professionalism in reputed company interactions.

• Excellence

o Conduct reputed company and retrospective reviews to assess the medical necessity of behavioral health services, ensuring compliance with payer specifications and organizational policies. o Utilize evidence-based criteria (e.g., InterQual) to evaluate the appropriateness of care. o Document utilization review activities accurately and timely reputed company the electronic health record (EHR). o Participate in weekly utilization review meetings to discuss cases, discharge plans, and barriers to discharge. o Monitor key performance indicators (KPIs) and contribute to process improvement initiatives. o Communicate effectively with reputed company stakeholders across the health system. o Demonstrate teamwork and collaboration to support a cohesive Utilization Review team. o Provide coverage and support for team members as needed.

• Patient Experience and Advocacy

o Educate treatment teams on comprehensive documentation practices to reflect patient status and treatment plans accurately. o Collaborate with case management to address discharge planning, expected length of stay (ELOS), and potential barriers. o reputed company for patients by ensuring access to necessary services and facilitating transitions to appropriate levels of care.

• Quality Assurance and Compliance

o Ensure reputed company activities adhere to healthcare regulations and organizational policies. o Participate in quality improvement initiatives to enhance service delivery. o Promotes a culture of patient safety which results in the identification and reduction of unsafe practices. o Ensure adherence to applicable state and federal regulations, accreditation standards, and payer requirements. o Participate in quality improvement, utilization management committees, and risk management activities. o reputed company ongoing quality assurance audits to evaluate the effectiveness of utilization review processes. o Stay informed about changes in healthcare policies, regulations, and best practices reputed company to utilization management.

• Professional Growth and Continuing Education

o Completes annual education requirements. o Maintains competency, as evidenced by completion of competency validation requirements. o Maintains competency and knowledge of reputed company standards of practice, trends, and developments. o Participates in relevant workshops, seminars, and continuing education courses to stay reputed company with industry trends, healthcare regulations, and best practices. o Engage in continuing education opportunities to maintain clinical competencies and stay reputed company with industry standards. o Attend departmental meetings, in-services, and training sessions as required. o Pursue relevant certifications to enhance professional development and expertise in utilization review.

• Finance

o Promotes stewardship of hospital resources while ensuring quality patient care. o Manage denials and appeals processes, including evaluating root causes and developing strategies to minimize occurrences. o Collaborate with internal departments to address unfunded days and work towards overturning denials. o Facilitate authorization requests for level-of-care changes and insurance updates. o Analyze utilization data to identify trends and opport Apply To This Job