RN - Utilization Reviewer - Coordinated Care

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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:

R00046700

Job Category:

Nursing

Organization:

Utilization Review

Location/s:

Main Campus Jackson

Job Title:

RN - Utilization Reviewer - Coordinated Care

Job Summary:

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 um process to the appropriate manager. To perform job duties in accordance with the medical center's purpose.

Education & Experience

Four (4) years RN experience, one (1) year of which must have been in performance improvement, utilization review, or case management.
 

CERTIFICATIONS, LICENSES OR REGISTRATION REQUIRED: 

Valid RN license. CPUM (certified professional in utilization management), ACM (accredited case manager), or CCM (certified case manager) preferred.

Knowledge, Skills & Abilities

Knowledge of the aspects of utilization review. Excellent interpersonal verbal and written communication and negotiation skills.  Skills in the use of personal computers and related software applications.
Ability to gather data, compile information, and prepare reports. Ability to identify process improvements. Good working knowledge of and understanding of medical procedures and diagnoses, procedure codes, including ICD-10, CPT, and DSM-IV codes.

Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement. Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families. Demonstrate commitment to the organIzation’s mission and the behavioral expectations in all interactions and in performing all job duties.  Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and commitment to continuous quality improvement (CQI) process.

Independent, focused and follow written instructions. Ability to use medical necessity guidelines with minimal supervision. Equipped to work remotely to include hardware with high speed internet via cable and Windows 10

RESPONSIBILITIES: 

• Performs all aspects of prospective, concurrent, retrospective and denials review for individual cases to include benefit coverage issues, medical necessity appropriate level of care (setting) and mandated services.    
• Assists in the collection and reporting of financial indicators including case mix, los, cost per case, excess days, resource utilization, readmission rates, denials and appeals. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction. Collects, analyzes and addresses variances from the plan of care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes. Collects delay and other data for specific performance and/or outcome indicators as determined by administrator - resource management. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning, care transitions and care coordination). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently.
• Applies approved clinical appropriateness criteria to monitor appropriateness of admissions, and continued stays, and documents findings based on department standards. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Refers cases and issues to care management physician advisor in compliance with department procedures and follows up as indicated. Communicates with third party payers to facilitate covered day reimbursement certification for assigned patients. Discusses payor criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Uses quality screens to identify potential issues and forwards information to clinical quality review department. Completes utilization management and quality screening for assigned patients. 
• Works collaboratively and maintains active communication with physicians, nursing, and other members of the inter-disciplinary care team to effect timely, appropriate patient management and eliminate barriers to efficient delivery of care in the appropriate setting. Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Utilizes conflict resolution skills as necessary to ensure timely resolution of issues. Collaborates with physicians and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing;  completion of treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communication to third party payers and other relevant information to the care team; assignment of appropriate levels of care; completion of all required documentation in epic screens and patient records. 
•  Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice. 
• Promotes individual professional growth and development by meeting requirements for mandatory/ continuing education, skills competency, supports department- based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff.
•  Actively participates in clinical performance improvement activities 
• 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. 

 

Environmental and Physical Demands: 

Requires occasional exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold, no handling or working with potentially dangerous equipment, occasional working hours beyond regularly scheduled  hours, occasional travelling to offsite locations, occasional activities subject to significant volume changes of a seasonal/clinical nature, occasional work produced is subject to precise measures of quantity and quality, occasional bending, occasional lifting/carrying up to 10 pounds, occasional lifting/carrying up to 25 pounds, no lifting/carrying up to 50 pounds, no lifting/carrying up to 75 pounds, no lifting/carrying up to100 pounds, no lifting/carrying 100 pounds or more, no climbing, no crawling, occasional crouching/stooping, no driving, occasional kneeling,occasional pushing/pulling, occasional reaching, frequent sitting,occasional standing,occasional twisting, and frequent walking.  (Occasional-up to 20%, frequent-from 21% to 50%, constant-51% or more)

Time Type:

Part time

FLSA Designation/Job Exempt:

No

Pay Class:

Hourly

FTE %:

100

Work Shift:

Benefits Eligibility:

Grant Funded:

Job Posting Date:

11/5/2025

Job Closing Date (open until filled if no date specified):