Utilization Management Nurse (RN)
Core
Provides administrative and clinical support to hospital and treatment teams regarding patient placement in various levels of care and receipt of necessary services.
Role type
Utilization Management Registered Nurse
Builds
Patient care authorization workflows and quality improvement processes
Domain
Healthcare administration / Utilization Review
Deliverable
client delivery
Required skills
Clinical case data synthesis, Insurance eligibility and benefits validation, Discharge planning coordination, Quality indicator identification, Data analysis for process improvement, Report preparation
Preferred skills
Prior Utilization Management experience, Multi-state RN licensure
Technologies
Microsoft Word, Excel, Access
Responsibilities
Gathers and prepares clinical/treatment information to obtain authorization within review intervals. Participates in treatment teams and Patient Care Committee to provide information on eligibility and criteria. Assists in discharge planning as needed. Identifies and reports Quality Improvement (QI) triggers. Reviews patient eligibility and benefits to validate level of care utilization. Investigates and prepares appeals for insurance companies regarding reimbursement denials. Participates in quality-of-care and UM process improvement initiatives. Provides staff education on UR goals.
Seniority
Mid-level, hands-on IC