May 17, 2022

Utilization Management Review Nurse

  • Memorial Health
  • Springfield, IL, USA
Full-time

Job Description

Performs clinical review of patient records to evaluate the utilization of acute care services. Communicates to third party payors to support the medical necessity of the hospital admission for services reimbursement. Ensures the patient care team is aware of general length of stay requirements for all patients. Facilitates physician documentation through concurrent interaction with physicians to support reimbursement and clinical severity is captured for the service rendered to patients receiving hospital care. Provides clinical knowledge and data collection for quality improvement initiatives. Optimizes reimbursement for acute care services.

*This is not a remote position*

Qualifications

Education:

Associates Degree in Nursing. Bachelor’s Degree in Nursing preferred.

Evidence of continuing professional development

Licensure/Certification/Registry:

Current RN licensure in the State of Illinois required

Experience:

Minimum of 3- 5 years of recent acute care and/or home health nursing or case management experience required. Previous utilization review experience strongly preferred.

Other Knowledge/Skills/Abilities:

Understanding of healthcare reimbursement mechanisms preferred.

Strong oral and written communication skills.

Demonstrated adaptability to changes in health care environment with proactive problem solving attitudes

Understanding of the principles of performance improvement, team collaboration, and conflict resolution