Utilization Review Nurse- Pool

Overview

Under the supervision of the Manager of Utilization Management, the Utilization Review RN conducts medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, Joint Commission, CMS, and other agencies. Prospectively, concurrently, or retrospectively determines the appropriateness of inpatient, observation, and extended recovery services following review of relevant medical documentation and medical guidelines.

The Utilization Review RN communicates information to payers in accordance with contractual obligations. The role also serves as a resource to physicians, collaborates with the Care Manager in the development and implementation of the plan of care, and collaborates with the Denials team to assist in preventing concurrent and retrospective denials. The Physician Advisor supports second-level clinical reviews for cases that do not meet medical criteria, complex cases, appropriate level of care, Medicare cases as required, and the need for Peer-to-Peer reviews.

Collaboration with the Physician Advisor supports policy development, process improvement, and staff education related to clinical denial mitigation.

Dayton Children s - Main Campus

Utilization Review Team

Part time

8

• Perform medical record review for medical necessity and level of care using approved indicators and criteria.
• Determine appropriateness of inpatient, observation, and extended recovery services prospectively, concurrently, or retrospectively based on documentation and guidelines.
• Communicate information to payers in accordance with contractual obligations.
• Serve as a resource to physicians and collaborate with the Care Manager in developing and implementing the plan of care.
• Collaborate with the Denials team to assist in preventing concurrent and retrospective denials.
• Support second-level clinical reviews with Physician Advisor for cases that do not meet criteria, complex cases, Medicare cases as required, and Peer-to-Peer reviews.
• Support policy development, process improvement, and staff education related to clinical denial mitigation.

• Completion of an accredited RN program with current RN license in Ohio required
• Graduate of an accredited BSN Nursing Program required

• Two years’ experience in the acute care setting, preferably in pediatrics.
• Current knowledge of reimbursement requirements, level of care criteria, APR-DRGs, MCG guidelines.
• Exceptional oral and written communication skills.
• Proficiency in Microsoft Word, Excel, PowerPoint and Epic Systems preferred.

• Bachelors:
  Nursing (Required)

• RN:
  Registered Nurse (RN) - Ohio Board of Nursing