Shift: 8:00AM - 5:00PM ET

Position Goal

The Utilization Review Nurse serves as a resource for other members of the healthcare team and provides education to team members on issues related to the continuum of care, reimbursement, regulatory agency guidelines and resource use.  Through collaboration, the Utilization Review Nurse assures that the treatment plan is implemented accurately, in a cost effective and efficient manner in order to promote customer satisfaction and prevent delays in care and discharge.

Responsible for reviewing severity of illness and intensity of service indicators to assure that appropriateness of care criteria is met.  Documents reviews in the medical record and/or the computer system as appropriate.  Collects and maintains data for tracking and reporting for outcome studies and performance improvement. Conducts admission, concurrent and retrospective utilization reviews for all assigned patients. Prepares as assigned special studies, assessments and committee reports. Assists Physician Advisors in concurrent review and in facilitating appropriate admissions and discharges to promote a high quality of care while preventing underutilization/over utilization of hospital resources.

Position Responsibilities:

• Performs admission, observation, concurrent and retrospective reviews to evaluate the medical necessity of hospital services during the patient’s stay.
• Coordinates the referral of cases to the Physician Advisor (PA) if not meeting approved criteria for admission or continued stay and distributes the Hospital Issued Notice of Non-coverage (HINN) when indicated.
• Ensures that all reviews are performed promptly.  Facilitates optimum patient outcome and performance improvement. 
• Assists in developing and maintain organization-wide polices and guidelines that provide structure for utilization review.
• Participates in Quality team activities as requested.
• Maintains information and generates appropriate paperwork and reports and forwards to appropriate department or committee.
• Coordinate utilization review with Business Office/Revenue Cycle to ensure compliance, maximize reimbursement and monitor and coordinate issues, such as when necessary RAC audit and other audits as they relate to the revenue cycle.
• Monitor, analyze and report the impact of utilization management influences on patterns of care and trends in length of stay. Maintains confidentiality of records, files and other data relevant to utilization and quality management activities.
• Coordinate monthly reports as required for review process for Quality Committees.

Experience:

Required:

• Minimum of 2 years of experience as an RN in an inpatient/acute care setting
• Minimum of 1 year of experience in Utilization Management

Education:

Required:

• Basic education necessary for Registered Nurse licensure

Special Qualifications:

Required:

• Current Alabama or Multi-State Nursing License required
• BLS certification required
• Working knowledge of healthcare reimbursement, counseling, community resources, continuum of care and team building
• Training in patient assessment home care planning and criteria review.

The Hughston Clinic, The Hughston Foundation, The Hughston Surgical Center, Hughston Clinic Orthopaedics, Hughston Medical, Hughston Orthopaedics Trauma, Hughston Orthopaedics Southeast and Jack Hughston Memorial Hospital participate in E-Verify. This company is an equal opportunity employer that recruits and hires qualified candidates without regard to race, religion, color, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.