Registered Nurse Utilization Review KMH

Salary: 74,431.50-111,637.50 USD

Facility: Kenmore Mercy Hospital

Shift: Shift 1

Status: Full Time FTE: 1.000000

Bargaining Unit: ACE Associates

Exempt from Overtime: Exempt: Yes

Work Schedule: Days with Weekend and Holiday Rotation

Hours:

8 am- 4 pm

Summary:

The Registered Nurse (RN), Utilization Review, as an active member of the Middle Revenue Cycle and interdisciplinary care team, provides comprehensive Utilization Review to patients and families in the hospital setting. Utilizing foundational nursing clinical skills Utilization Review nurse collaborates with the interdisciplinary team to maintain appropriate levels of care and to facilitate movement of the patient through the continuum. The Utilization Review RN identifies and removes barriers for delays of treatment. This individual also works to maintain third-party payer relationships related to Utilization Review Activities. This includes, but is not limited to, concurrent review, responding to inquiries, complaints, and other correspondence, and may include setting up discussions between parties. Knowledge of state and federal laws relating to contracts and utilization review process processes is vital.

Responsibilities:

EDUCATION

• BSN degree or RN with a BS in health-related field and working knowledge/experience in documentation utilization review in an acute care/inpatient setting
• Unrestricted NYS RN license
• Holds, or will obtain within one year of hire, Certified Case Manager (CCM)
• Certification in a Nationally Recognized Utilization Review Criteria set is preferred
• At least 1 year of experience in working with third party payers strongly preferred

EXPERIENCE

• Minimum of three (3) years of experience working in an Acute Care Hospital Setting
• Proficiency in utilization management and regulatory requirements preferred
• Experience in working with people who are geographically dispersed preferred
• Experience in working with third party payers strongly preferred

KNOWLEDGE, SKILL AND ABILITY

• Strong clinical assessment skills and ability to articulate findings in a fast-paced environment. Possess the ability to make independent decisions within the professional scope of practice
• Possess ability to educate, inform, advocate, promote and facilitate health care options, and demonstrate the willingness to work harmoniously with a team approach
• Possesses ability to effectively and efficiently utilize technology within daily work with the care team and ability to quickly learn and adapt to new technology tools and software
• Extensive knowledge of third-party payer guidelines, accreditation and regulatory requirements preferred
• Knowledge of Managed Care Organization contracts/agreements preferred

WORKING CONDITIONS:

• Willingness to work beyond normal working hours, and in other positions temporarily, and/or at other locations when necessary
• Variable schedule which may include weekends and holidays. May be requested to travel to multiple hospital and community sites

ENVIRONMENT

• Normal heat, light space, and safe working environment; typical of most office jobs
• Occasional exposure to one or more mildly unpleasant physical conditions
• Minimum physical effort required, typical of most office work
• Significant amount of walking within the acute care facility