POSITION SUMMARY:
The Utilization Review Nurse ensures the delivery of cost-effective quality care within an appropriate length of stay.
JOB SPECIFIC RESPONSIBILITIES:
General Responsibilities:
• Maintains PHI and HIPAA for each patient in accordance with hospital policy and federal regulations.
• Promotes safety in the workplace and a safe patient environment at all times
• Practices “minimum information necessary” when performing UR, case management, and discharge functions
• Acts as a patient advocate for all facility patients
• Adheres to all company and professional ethical, legal, and accreditation/regulatory standards
• Respects and promotes individual patient privacy and confidentiality
• Demonstrates knowledge and support of the organization's mission, vision, values, and strategic initiatives.
• Demonstrates understanding of and upholds the organization’s Quality, Risk, and Continuum of Care program
philosophy.
UTILIZATION REVIEW MANAGEMENT (UM) RESPONSIBILITIES (75% of time performing duty)
• For all hospital admissions, this position will review medical necessity within two business days of admission and
will be based on medical record documentation on the chart within 48 hours of admission and document using
the appropriate UR form. Assist with Pre-admission referral reviews and concurrent and discharge criteria
reviews, as needed.
• Completes ongoing concurrent and discharge UM reviews at least every seven days or as required by the payor.
All UM reviews will be documented per policy. Follows the UM process for referral of cases to Physician
Advisor/Medical Director when appropriate.
• Participates in weekly UM meetings to review all outstanding cases for appropriateness of admission and
discharge and the need for continued stay. Identifies potential barriers and obtains appropriate physician
intervention when necessary.
• Completed all UM reviews within stated time frames and follows UM process for additional clinical reviews when
necessary.
• Provides clinical updates to third-party payors after admission within stated time frames to obtain continued stay
authorization. All interactions and results of interactions with third-party payors are documented in the
• MEDITECH system. This documentation includes the level of care, number of days approved, and next review due date.
• Provides utilization management equally to all patients regardless of payor source.
• Maintains documentation in the chart in a timely fashion and communicates any changes timely to third-party
payors to update authorization of ongoing medical care appropriate to patient needs.
• Follows clinical review process to assist in the appropriate management of patient medical services and facilitate
discharge to the appropriate level of care in a timely and cost-effective manner.
• Identifies/tracks/trends/analyzes selected variations (variance=patient/family, practitioner, system, or
community) which affect patient care, resource management or length of stay. Completes statistical and other
reports as required in a timely manner.
• Ensures utilization of medical resources for patients efficiently and effectively
• Maintains a safe environment
• Participates in Quality Improvement, UM Committee, and Risk Management as indicated
• Attends department meetings and mandatory in-services.
Performs other duties as assigned.
POSITION QUALIFICATIONS:
EDUCATION:
• Minimum Bachelor’s degree in a Health care field.
• Bachelor’s degree in nursing (BSN) desired.
EXPERIENCE:
• Two (2)-three (3) years of experience in hospital case management, utilization management, or discharge
planning of complex medical/surgical cases
• Proficient in evaluating complex clinical documentation
• Strong analytical and organizational skills
• Working knowledge and ability to apply professional standards of practice in the work environment.
• Knowledge of specific regulatory, managed care, and accreditation requirements
• Computer proficiency
LICENSURE/CERTIFICATION:
• Must maintain current licensure in good standing during employment, as applicable.
• Must obtain CEUs in accordance with state requirements for licensure.