The Utilization Review (UR) Nurse assesses the medical necessity, level of services, and appropriateness of care in individual cases requiring prospective, concurrent or retrospective utilization review. Evaluates the patient’s needs and appropriate services.
- Reviews patient medical records applying utilization criteria, norms and clinical knowledge to assess the medical necessity, level of services, and appropriateness of care in individual cases.
- Prepares confidential documentation on the results of the case review, records variations on screening sheets and interfaces with necessary individuals for follow-up.
- Must be able to coordinate with department physician advisors, Nursing, Social Service, Infection Control, Medical Records, other departments/personnel and community resources to ensure continuity along the continuum of care.
- Must be able to review patient record, identify variant patterns of care, using comprehensive screening methods, including utilization review criteria.
- Performs quality assurance functions of coordination, monitoring and reporting of quality assurance studies according to the UR plan.
- Responsible for knowing current QA and UR regulations and informing others of regulation changes.
- Collects and compiles information for special projects if necessary.
- Reports identified or possible variations to appropriate supervisor.
- Completes other assignments as requested and assigned.
- May have access to personal health information ("PHI") necessary to fulfill the above duties and responsibilities. Access to use and ability to disclose PHI is further defined by each organization/department.
Minimum Education & Experience Requirements:
- Registered Nurse experience with active license in the state(s) in which he/she is employed and practices.
- One (1) year UR nursing experience within the last five (5) years.
- Case Management experience as defined by the contracting employer.
Knowledge, Skills & Abilities Required:
- Able to effectively communication with clinical, non-clinical staff, providers, outside organizations, patent and family/caregivers.
- Able to demonstrate skill in quality assurance/utilization review process.
- Able to effectively communicate with the clinical and non-clinical community.
- Able to demonstrate basic understanding of computers and workplace software.
- Able to demonstrate skills in consultation, collaboration and systems management.
- Able to provide proof of a valid driver’s license, if applicable.
- Able to provide proof of valid auto liability insurance if assignment(s) include driving own vehicle.
- Meets applicable health requirements to provide patient care.
Working Conditions & Physical Effort:
- Work is performed in clinics, schools, hospitals, nursing homes or occupational settings.
- Requires ability to sit for long periods.
- Requires normal, correctable vision and hearing.
- Work environment may involve occasional exposure to communicable diseases, blood borne pathogens and/or potentially infectious or hazardous materials.
- Physical activity is medium and may require occasional lifting, carrying, pushing or pulling up to 50 lbs.
- Case Management
- Certified Nurse Practitioner
- Clinical Works
- Contract Management