Staff Nurse - Utilization Review; ED

SUMMARY:

We are currently seeking a Staff Nurse to join our Utilization Management department for the Emergency Department. This position is a 0.8 FTE (8 shifts/ pay period), 8-hour shifts, Evenings (4:30 pm-1 am), with up to Every Other Weekend rotation.

Note:

Current weekend assignment is typically every 2-3 weeks however is subject to change based on staffing needs and may require up to Every Other Weekend coverage.

SPECIFIC RESPONSIBILITIES:

The Utilization Review (UR) Registered Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities. The RN conducts timely reviews of inpatient and outpatient medical records to determine the appropriateness of admissions, continued stays, and the level of care using established criteria and guidelines (e.g., Inter Qual, MCG). This role collaborates with healthcare providers, patients, payers, and internal departments to ensure quality care while optimizing resource utilization and controlling costs.

Assessment:

• Collects, reviews, and documents clinical data relevant to utilization management, including patient status, treatment plans, and healthcare utilization. Applies nationally recognized criteria (e.g., Inter Qual, MCG) to assess the appropriateness of services.

Outcomes Identification
:

• Identifies expected outcomes related to care transitions, resource use, and reimbursement to optimize patient health outcomes and reduce unnecessary utilization.

Planning:

• Develops a utilization management plan by coordinating with clinical teams, payers, and discharge planners to support timely care progression and appropriate resource use.

Implementation:

• Implements review processes to evaluate necessity and efficiency of services. Initiates communication with physicians and payers to resolve authorization issues and prevent delays in care.

Evaluation
:

• Continuously evaluates the appropriateness of hospital admissions, continued stays, and treatment plans in accordance with payer guidelines and evidence-based practice.

Quality of Practice
:

• Promotes quality through evidence-based utilization review processes and actively contributes to performance improvement initiatives.

Education
:

• Attains and maintains current knowledge in UR/UM practices, payer requirements, clinical guidelines, and regulations affecting utilization management.

Professional Practice
:

• Evaluates personal practice against professional standards, licensing requirements, and Hennepin Healthcare policies.

Collegiality:

• Collaborates with nursing, providers, case management, finance, and payer representatives. Contributes to professional development by sharing knowledge and supporting team education.

Collaboration:

• Utilizes principles of relationship-based care to collaborate with care teams, patients, families, and external entities to facilitate effective care coordination and appropriate resource utilization.

Ethics:

• Applies ethical decision-making when handling authorization issues, appeals, and coverage decisions. Advocates for patient needs while balancing organizational goals and payer requirements.

Evidence-Based Nursing Practice and Nursing Research
:

• Applies evidence-based criteria for utilization review decisions. Supports data collection and reporting to enhance outcomes.

Resource Utilization:

• Considers safety, effectiveness, cost, and legal compliance when recommending levels of care or authorizations. Ensures documentation supports accurate coding, billing, and compliance.

Leaderhip:

• Demonstrates leadership through decision-making, communication with multidisciplinary teams, and proactive problem-solving related to authorization and utilization challenges.

Self-Evaluation:

• Reviews and reflects on own practice related to guidelines, regulations, and departmental goals.

Safe Practice:

• Participates in maintaining a safe, efficient, and regulatory-compliant work environment; adheres to Hennepin Healthcare’s protocols and confidentiality standards.

Provide Education and Mentorship:

• Demonstrates knowledge and application of adult learning needs and principles. Understands, articulates, and promotes the HHS Nursing Vision and Practice…