Job Description

The Utilization Review Nurse is responsible for the coordination and direction of all utilization review activities to support and implement the goals of the utilization review program and plan. The U/R Nurse prepares and presents utilization review reports to the Utilization Review Committee and other committees/stakeholders. The U/R Nurse maintains and updates policies and procedures for utilization review, swing bed, and discharge planning.

Responsibilities/Duties:

• Evaluates medical services provided to ensure they are necessary, cost-effective, and align with organizational guidelines and policies.
• Collaborate with providers, insurance companies, and patients to optimize care while ensuring compliance with regulatory standards, with a focus on:
• Precertification:
  • Collaborate with the access management team and Physicians to obtain precertification/authorization and have accurate admissions orders. Confirm medical necessity and level of care as requested. Work with house Supervisors as needed to ensure the level of care is appropriate.
• Access to Care:
  • Work closely with Patient Financial Services on payment denials and appeals. Perform intake assessments within 24 hours of admission (excluding holidays & weekends) and perform follow-up assessments. Collaborate with physicians when questioning support of inpatient status to influence appropriate utilization of resources, accurate status determination, and transition of care.
• Continued Stay:
  • Participate in daily huddles, multidisciplinary rounds, patient care conferences, and physician/nurse hand-off reports have awareness of progression of care, observation, and extended stay surgical outpatients. Identify and record episodes of preventable or avoidable delays due to failure of progression-of-care processes. Educate members of the patient care team on the uses of various levels of care as needed. Coordinates UR committee meetings and activities, including standard reports, and conducts and reports results of periodic audits.
• Transition:
  • Confirms patients’ readiness for discharge by consulting with the care team, social services, third-party payors, and individuals related to the patient to confirm agreement concerning discharge plans.
• Conduct certification reviews on all admissions.
• Gather patient data and document review information into a computer database for tracking.
• Prepare reports and implement and monitor changes associated with departmental improvement.

Education/Experience:

• Current RN licensure in the state of WI is required.
• BSN preferred.
• At least two years of nursing experience required, four years preferred.
• Two years of utilization review experience preferred.
• Knowledge of care criteria (e.g., InterQual Level of Care Criteria or MCG) and knowledge of local and national coverage determinations and documentation thereof in EMS preferred.