Utilization Review Registered Nurse (RN)
- Conduct admissions concurrent with retrospective utilization reviews for patients by screening inpatient and observation admissions to determine if they meet criteria for hospitalization.
- Stay current on changes in screening criteria.
- Assist the Utilization Review Coordinator in researching/preparing correspondence (insurance appeal letters, insurance denial of payment for stay letters).
- Maintain effective, appropriate and professional communication with hospital staff, care providers, peer review, commercial insurance review entities, and third-party payors to assure maximum reimbursement.
- Screen and assess patients for discharge planning based on age-related needs and make appropriate referrals to community agencies/hospital departments to assure continuity of care.
- Assist with hospital’s Swing Bed Program to identify and assure proper placement of candidates; inform physicians of possible placements in Swing Bed Program.
- Communicate with admitting/attending physicians regarding documentation and precertification requirements; maintain record of patient while hospitalized and work with physician to ensure optimal discharge planning.
- Comply with best practices in nursing and established hospital policies/procedures to render care of patients.
- Serve as Charge Nurse, as assigned.
• Licensed Registered Nurse in the State of Michigan required.
• Minimum of 2 years previous RN nursing experience required.
• Basic Cardiac Life Support (BCLS) certification or ability to obtain within 1 month of hire.
• Experience in Utilization Review and knowledge of DRG reimbursement system preferred.
• Ability to manage a diverse workload and prioritize tasks; assume management responsibilities as needed.
• Ability to physically and mentally carry out the functions of this position.
• Exceptional customer service skills with a professional demeanor that ensures trust, competence and compassion amongst patients, providers and team members.
• Ability to successfully pass a pre-hire drug screening and background check.