Reports To : Director of Nursing; Acute and Emergency Department
FLSA Classification: Part-Time, Non-Exempt, Hourly $33.50 - $49-53
Essential Functions:
The Part-Time Utilization Review Nurse is a Registered Nurse (RN) responsible for conducting utilization reviews to determine the medical necessity and appropriateness of patient admissions, continued hospital stays, and the level of care provided. This role ensures compliance with regulatory requirements and payer guidelines, proactively identifies potential barriers to discharge, and works to prevent claim denials, thereby supporting efficient patient throughput and optimal resource utilization within the hospital.
- Perform concurrent and retrospective utilization reviews for all patient admissions and continued stays, applying established medical necessity criteria (e.g. InterQual, Milliman Care Guidelines), and payer specific guidelines.
- Communicate effectively with attending physicians, residents, and other healthcare providers regarding medical necessity, documentation requirements, and alternative levels of care.
- Identify and address potential barriers to discharge, collaborating with the Case Management team to facilitate timely patient progression.
- Document all review activities, including approvals, denials, and appeals processes, accurately and thoroughly in the electronic health record (EHR) system.
- Assist in the preparation and submission of appeals for denied services, providing clinical rationale and supporting documentation.
- Stay current with Medicare, Medicaid, and commercial payer regulations, policies, and medical necessity criteria.
- Collaborate with the Case Management team to ensure seamless coordination between utilization review and discharge planning activities.
- Participate in interdisciplinary team meetings to discuss patient status, care progression, and discharge readiness.
- Provide education to physicians and other staff on documentation requirements for medical necessity.
- Monitor readmissions and avoidable days in Meditech for quality improvement initiatives.
- Coordinate in advance discharge planning for orthopedic surgical patients, ensuring timely referrals, equipment orders, and post-discharge services.
- Actively participate in the Utilization Review (UR) Committee.
- Perform other duties as assigned to support utilization management, case management, and hospital operations.
- Other duties as assigned.
Education and Experience:
- Previous experience in managing staff and schedules required.
- Active, unencumbered Registered Nurse (RN) license in Colorado or Compact-state license that includes Colorado.
- Two (2) to three (3) years’ of recent clinical experience in an acute care setting required.
- One (1) year of experience in Utilization Review or Case Management preferred.
- Strong knowledge of Medicare, Medicaid, and commercial payer regulations, as well as medical necessity criteria (e.g., InterQual, Milliman Care Guidelines).
Pioneers' history began in 1947 when Freeman Fairfield, a previous resident of this community, approached the County Commissioners about establishing a hospital. Over the next several years, Mr. Fairfield worked with the Commissioners and a group of local citizens to build a hospital for the Meeker community. Opening its doors in 1950, Pioneers began offering acute health care and surgical services to the community, licensed through the State of Colorado Department of Health and Human Services. We are Medicare and Medicaid-certified, accept private insurance, and, of course, self-pay. Financial arrangements may be set up through the Business Office.
In 1964, the Walbridge Memorial Convalescent Wing opened its doors for long-term care, made possible through the generosity of the wills of Carl and Adelaide Walbridge. Attached to the north side of the hospital, the Wing, with its 33 beds, brings skilled and intermediate nursing to residents who are unable to care for themselves. Through the Wing's rehabilitation services, exercise, and activity groups, each resident's care is individualized to meet his or her physical, emotional, nutritional, and spiritual needs. The Wing is licensed by the State of Colorado Department of Health and Human Services, and accepts Medicare, Medicaid, and private-pay residents.
First-line health care services are delivered through Meeker Family Health Center. The MFHC originated in 1990 as a rural health clinic, and its physicians, nurse practitioners, and staff continue to strive to meet our community's and visitors' healthcare needs.
