Description
Summary
The Utilization Review Nurse is responsible for evaluating the medical necessity and appropriateness of healthcare services and treatment as prescribed by utilization review standards. The UR Nurse works with providers, insurance companies and patients to ensure cost-effective and appropriate care. Areas of work include status management, medical necessity reviews, verification of authorization, resource utilization, and denial prevention.
Responsibilities
Completes and enters inpatient and observation admission review against standard criteria per payer guidelines
Prioritizes observation case review
Assists with level of care in collaboration with attending provider
Enters working diagnosis-related groups (DRGs) in the electronic medical record
Submits clinical information to payer per payer requirements
Completes continued stay reviews every 3 days or more often if required
Communicates with care coordinators for authorized days, level of care, medical necessity or other areas when indicated
Communicates with physician advisors related to status concerns or denials
Updates auth/cert screen in the electronic medical record
Works assigned queues in the electronic medical record
Communicates with authorization coordinator
Communicates in-house high dollar case information
Completes assigned goals
Requirements, Preferences and Experience
Experience Minimum:
RN with 3 years of clinical experience
Experience Preferred:
RN with 3 years of clinical experience
Education Minimum:
Diploma or Associate Degree in Nursing
Education Preferred:
BSN or MSN
Special Skills Minimum:
Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills. Problem solving; and knowledge of governmental regulations.
Licensure Minimum:
RN
Licensure Preferred:
CCM;ACM
About Baptist Memorial Health Care
At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry-healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey.
At Baptist, We Offer:
Competitive salaries
Paid vacation/time off
Continuing education opportunities
Generous retirement plan
Health insurance, including dental and vision
Sick leave
Service awards
Free parking
Short-term disability
Life insurance
Health care and dependent care spending accounts
Education assistance/continuing education
Employee referral program
Job Summary:
Position: 19738 - RN-Utilization Review
Facility: BMHCC Corporate Office
Department: HS Case Mgmt Administration Corporate
Category: Nurse RN
Type: Clinical
Work Type: Full Time
Work Schedule: Days
Location: US:TN:Memphis
Located in the Memphis metro area REQNUMBER: 23201
Compensation Information:
$0.0 / - $0.0 /
Starting At: 0.0
Up To: 0.0
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