Overview RN Utilization Review Weekender Job Code: 22818 FLSA Status Job Family: NURSING Job Description Title: RN Utilization Review Weekender Job 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. Job 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 Specifications Experience Description Minimum Required: RN with 3 years of clinical experience Preferred/Desired: RN with Case Management or Utilization Review experience in a hospital or payer setting Education Description Minimum Required: Diploma or Associate Degree in Nursing Preferred/Desired: BSN or MSN Training Description Minimum Required Preferred/Desired Special Skills Description Minimum Required: Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills. Problem solving; and knowledge of governmental regulations. Preferred/Desired Licensure Description Minimum Required: RN Preferred/Desired: RN;CCM;ACM Reporting Relationships Does this position formally supervise employees? If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager. Reporting Relationships: No Work Environment Functional Demands Label Short Description Full Description Sedentary Very light energy level Lift 10lbs. box overhead. Lift and carry 15lbs. Push/pull 20lbs. cart Light Moderate energy level Lift and carry 25-35lbs. Push/pull 50-100lbs. (ie. empty bed, stretcher) Medium High energy level Lift and carry 40-50lbs. Push/pull +/- 150-200lbs. (Patient on bed, stretcher) Lateral transfer 150-200lbs. (ie. Patient) Heavy Very high energy level Lift over 50lbs. Carry 80lbs. a distance of 30 feet. Push/pull > 200lbs. (ie. Patient on bed, stretcher). Lateral transfer or max assist sit to stand transfer. Functional Demands Rating: Light Activity Level Throughout Workday Physical Activity Requirements – Sitting: Frequent Physical Activity Requirements – Standing: Occasional Physical Activity Requirements – Walking: Occasional Physical Activity Requirements - Climbing (e.g., stairs or ladders): Occasional Physical Activity Requirements - Carry objects: Occasional Physical Activity Requirements - Push/Pull: Occasional Physical Activity Requirements – Twisting: Occasional Physical Activity Requirements – Bending: Occasional Physical Activity Requirements - Reaching Forward: Occasional Physical Activity Requirements - Reaching Overhead: Occasional Physical Activity Requirements - Squat/Kneel/Crawl: Occasional Physical Activity Requirements - Wrist position deviation: Occasional Physical Activity Requirements - Pinching/fine motor activities: Frequent Physical Activity Requirements - Keyboard use/repetitive motion: Continuous Physical Activity Requirements - Taste or smell Physical Activity Requirements - Talk or hear: Frequent Sensory Requirements Color Discrimination: Yes Near Vision: Very Accurate Far Vision: Accurate Depth Perception: Minimal Hearing: Minimal Environmental Requirements - Blood-Borne Pathogens: Anticipated Environmental Requirements – Chemical: Anticipated Environmental Requirements - Airborne Communicable Diseases: Anticipated Environmental Requirements - Extreme Temperatures: Not Anticipated Environmental Requirements – Radiation: Not Anticipated Environmental Requirements - Uneven Surfaces or Elevations: Not Anticipated Environmental Requirements - Extreme Noise Levels: Not Anticipated Environmental Requirements - Dust/Particular Matter: Not Anticipated Environmental Requirements - Other REQNUMBER: 31011