The Utilization Review RN Specialist reviews and monitors utilization of health care services with the goal of maintaining high quality cost-effective care.
Posted Sep 29 · 3 years of experience
Shift and hours
At least 8 shifts per month Seeking Applicants That Can Work at Least 8 Shifts per Month
Unit and setting
Case Management Department: Case Management
License
RN license Registered Nurse (RN) - License State And/Or Compact State Licensure RequiredRegistered Nurse (RN) - License State And/Or Compact State Licensure
Term
Per Diem Registered Nurse - Utilization Review Per Diem
Do you qualify?
License
Registered Nurse (RN) - License State And/Or Compact State LicensureRegistered Nurse (RN) - License State And/Or Compact State Licensure RequiredCheck your license
Education
Associates in Nursing from an accredited NLN/CCNE institutionAssociates in Nursing from an accredited NLN/CCNE institution Required or
Experience
1 year experience in UR/UM or Case Management1 year experience in UR/UM or Case Management Required
Experience
3 years Registered Nurse in an acute care setting
Preferred
Certification
Certified Case Manager - Certification Certified Case Management (ACM) Case Management CertificationCertified Case Manager - Certification Certified Case Management (ACM) Case Management Certification Preferred
Education
Bachelors in Nursing from an accredited NLN/CCNE institutionBachelors in Nursing from an accredited NLN/CCNE institution Preferred
review clinical documentation and facilitate modifications for level of service and severity of illness
Day to day
initial and concurrent reviews on all patients entering health care continuumPerforms initial and concurrent reviews on all patients entering the health care continuum.
Day to day
facilitate service delivery through effective utilization of available resourcesFacilitates the delivery of services to patients and families through effective utilization of available resources.
Day to day
perform medical record reviews as required by payerPerforms medical record reviews, as required by payer.
Day to day
interface with Care Management team regarding quality outcome measurementsInterfaces with Care Management team to provide information regarding quality outcome measurements (such as timeliness and appropriateness of services).
Day to day
collaborate to appeal individual denials and trended contract issuesCollaborates with physicians, case managers, payers and others to appeal individual denials and trended issues related to contract guidelines.
Day to day
develop documentation systems for data reporting with medical records, finance, and physician groupsWorks with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.
Day to day
initiate chart reviews, conduct follow-up reviews, and round on patientsInitiates chart reviews, conducts follow-up reviews, and rounds on patients to ensure continuity of UR reviews.
Day to day
maintain admission identification system for specific diagnosis / DRG classificationsMaintains a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions.
Day to day
notify attending physicians and staff of documentation clarification issuesNotifies attending physicians and house staff or other appropriate staff of documentation issues requiring clarification.
Day to day
determine hospital level of care qualifications based on set criteriaDetermines qualifications for hospital level of care based on set criteria.
Day to day
other duties as assignedPerforms other duties as assigned.
Seeking Applicants That Can Work at Least 8 Shifts per Month
Great care starts with great people. (Like you.)
At HonorHealth, you’ll find something special. From humble beginnings in 1927 to one of Arizona’s largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most — caring for the health and well-being of people and communities across the greater Phoenix area.
Responsibilities
Job summary
The Utilization Review RN Specialist reviews and monitors utilization of health care services with the goal of maintaining high quality cost-effective care. Ensures appropriate level of care through comprehensive review for medical necessity of extended stay, outpatient observation, and inpatient stays and the utilization of ancillary services. Responsible for coordinating and conducting medical necessity reviews for all Medicare, AHCCCS, Self-pay, and all other payers, upon admission and concurrently throughout the admission.
Essential functions
Reviews clinical documentation and facilitates modifications (as needed) to ensure that documentation accurately reflects the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients. Performs initial and concurrent reviews on all patients entering the health care continuum.
Facilitates the delivery of services to patients and families through effective utilization of available resources. Performs medical record reviews, as required by payer. Interfaces with Care Management team to provide information regarding quality outcome measurements (such as timeliness and appropriateness of services). Collaborates with physicians, case managers, payers and others to appeal individual denials and trended issues related to contract guidelines. Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.
Initiates chart reviews, conducts follow-up reviews, and rounds on patients to ensure continuity of UR reviews.
Maintains a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions. Notifies attending physicians and house staff or other appropriate staff of documentation issues requiring clarification.
Determines qualifications for hospital level of care based on set criteria.
Performs other duties as assigned.
Education
Associates in Nursing from an accredited NLN/CCNE institution Required or
Bachelors in Nursing from an accredited NLN/CCNE institution Preferred
Experience
1 year experience in UR/UM or Case Management Required
3 years Registered Nurse in an acute care setting. Required
Licenses and certifications
Registered Nurse (RN) - License State And/Or Compact State Licensure Required
Certified Case Manager - Certification Certified Case Management (ACM) Case Management Certification Preferred
