Utilization Review Nurse
Posted on: July 26, 2022
Summary / Objective: The Utilization Review Nurse performs
reviews for enrollees across the service continuum
(pre-certification / authorization, concurrent and retrospective
reviews) utilizing InterQual, NCD, and LCD criteria to ensure the
quality, quantity, timeliness and effectiveness of service. The
nurse acts in a non caregiver capacity by facilitating coordination
and communication between all members of the health care team in
the decision making process to minimize fragmentation of the health
care delivery system. As a member of the Utilization Management
Department, this position is responsible for contributing to the
standards of quality and service expected by both external and
internal stakeholders, including ensuring accurate information
flows to interdepartmental teams, proper documentation and
adherence to standards related to case management
- Reviews requests as required, performs preadmission, and
concurrent reviews for appropriateness of admission, continued
stay, length of stay, utilization of resources, patient outcomes
and discharge planning needs.
- Includes acute patient hospital, post-acute Skilled Nursing,
Long-Term Care, and Inpatient Rehab reviews for appropriateness of
level of care requested.
- Use established criteria and policy/procedures to perform
pre-admission, admission, and continued stay reviews on inpatient
and skilled nursing cases in accordance with NCQA and CMS
- Issue pre-authorization decisions for services requested such
as Durable Medical Equipment (DME), planned surgeries, medication
requests, etc.; notifying providers/enrollees of denials verbally
and in writing.
- Assess need to involve medical director on complex medical
costs or denials.
- Identify at-risk members in need of case/disease management
programs and complete appropriate referrals.
- Works with Interdisciplinary Team (IDT) to assist with delivery
of well-coordinated high quality health care, and tracking and
escalation of high dollar cases.
- Assist Case Management Team with care coordination during acute
episodes and transitions in care.
- Participate in department initiatives and projects focused on
- Participate in cross-training of clinical and non-clinical
roles, as appropriate, to ensure understanding of processes driving
compliance, turnaround times, and authorization workload
- Document all interventions and telephone encounters with
providers, members and vendors in accordance with established
- Exceed expectations in professional and personalized service
level to internal and external partners.
- Implement new policies, procedures and initiatives as assigned
and ensure all areas are maintained in accordance with company
policy, state, federal and plan regulatory mandates.
- Support technology implementations focused on opportunities to
scale and automate components of the UM process to improve
compliance tracking (e.g. fax software, authorization system
- Collaborates with internal and external healthcare team members
to achieve organizational IP, ED, SNF utilization, length-of-stay,
and readmission goals.
- Build and leverage cross-functional collaborative relationships
to support tracking of inter-related utilization, cost, and claims
- Promotes continuity of care and cost effectiveness through
integrating functions of case management and utilization review to
identify barriers to optimal patient care.
- Assess member physical, psychological and discharge planning
needs through communication with appropriate care providers to
coordinate care accordingly.
- Work with members and providers to enhance the quality of
patient management and satisfaction.
- Prepares and provides reports to leadership, other departments,
and outside agencies as needed.
- Support comprehensive training for new employees to ensure
mastery of work product and clear expectations.
- Continues own education by keeping knowledge current and
familiarity with guidelines to strengthen general understanding of
state and federal resources to support position
- Ensures compliance with departmental and PSW policies and
procedures, with special emphasis on compliance with HIPAA privacy
and security requirements and all state, federal and plan
- Is aware of and continually supports strategic plans that
ensure company objectives and goals are obtained.Required Education
and/or Work Experience:
- Minimum 2 years of experience in UM/UR.
- Verifiable experience or knowledge of a variety of clinical
areas of medical treatment.
- Knowledge of hospital/patient care facilities, current
practices, procedures, acceptable medical treatment and
- PSW requires all employees and contractors to be fully
vaccinated for COVID-19 as a condition of employment, subject to
reasonable accommodation. Each TRC health system requires visitors
adhere to its own COVID policy.Preferred Education and/or Work
- Case Manager Certification.
- Experience with health plan/HMO utilization review/management
and/or case management experience.
- Knowledge of Interqual and/or Milliman Utilization
- Experience working with Medicare Advantage/CMS.
Keywords: PSW, Olympia , Utilization Review Nurse, Healthcare , Olympia, Washington
Didn't find what you're looking for? Search again!