RN - Utilization Review - Utilization Review

Responsibilities

• Performs prospective, concurrent, retrospective, and denials review for individual cases, including benefit coverage, medical necessity, appropriate level of care, and mandated services.
• Assists in collecting and reporting financial and performance indicators, including case mix, length of stay, cost per case, resource utilization, readmission rates, denials, and appeals.
• Uses data to drive decisions and implement performance improvement strategies related to case management, including fiscal, clinical, and patient satisfaction outcomes.
• Collects and analyzes variances from the plan of care and collaborates with physicians and the healthcare team to address issues and improve outcomes.
• Applies clinical appropriateness criteria to monitor admissions and continued stays, identifies at-risk populations, and refers cases to the care management physician advisor as needed.
• Communicates with third-party payers to facilitate reimbursement certification, resolves payor issues, and completes utilization management and quality screening for assigned patients.
• Works collaboratively with the interdisciplinary care team to ensure timely, appropriate patient management, remove barriers to care, and proactively address delays or discharge obstacles.
• Ensures safe, high-quality care in compliance with policies, procedures, and standards, while managing time, supplies, productivity, and accuracy within budgetary guidelines.
• The duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time.
• Physical and Environmental Demands:

Benefits

Additional Information

Hello, Thank you for your interest in career opportunities with the University of Mississippi Medical Center. Please review the following instructions prior to submitting your job application: Provide all of your employment history, education, and licenses/certifications/registrations. You will be unable to modify your application after you have submitted it. You must meet all of the job requirements at the time of submitting the application. You can only apply one time to a job requisition. Once you start the application process you cannot save your work. Please ensure you have all required attachment(s) available to complete your application before you begin the process. Applications must be submitted prior to the close of the recruitment. Once recruitment has closed, applications will no longer be accepted. After you apply, we will review your qualifications and contact you if your application is among the most highly qualified. Due to the large volume of applications, we are unable to individually respond to all applicants. You may check the status of your application via your Candidate Profile. Thank you, Human Resources Important Applications Instructions: Please complete this application in entirety by providing all of your work experience, education and certifications/ license. You will be unable to edit/add/change your application once it is submitted. Job Requisition ID: R00050784 Job Category: Nursing Organization: Utilization Review Location/s: Main Campus Jackson Job Title: RN - Utilization Review - Utilization Review Job Summary: RN-Utilization Review is accountable to perform utilization management services for designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the utilization management process to the appropriate manager. Education & Experience Education and Experience Required: One (1) year of nursing experience in an inpatient setting. Certifications, Licenses, or Registration required: Valid RN license. Knowledge, Skills & Abilities Knowledge, Skills, and Abilities: Knowledge of utilization review, discharge planning, case management, and managed care reimbursement. Strong working knowledge of medical procedures, diagnoses, and procedure codes, including ICD-10, CPT, and DSM-IV. Excellent interpersonal, verbal, written communication, and negotiation skills. Ability to gather data, prepare reports, and identify process improvements. Able to work independently, exercise sound judgment, and apply medical necessity guidelines with minimal supervision. Committed to quality patient care, customer service, safety, cost efficiency, and continuous quality improvement (CQI). Proficient in the use of computers and related software applications.

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