Utilization Review Nurse

Currently hiring for Utilization Review Nurse in the Chicagoland surburbs. They are currently hiring for someone excited to grow with a large hospital system on their commercial team.


Official Job Description:

Performs initial and concurrent review on inpatient, skilled nursing facility, acute rehab, long term acute care and home health cases. Determines medical necessity by application of criteria per Milliman Care Guidelines, Utilization Management Department Policies, specific Health Plan guidelines, and CMS regulations. Recommends an increase or decrease in level of care/equipment/service based upon medical condition and physician orders.
Refer all services that do not meet established criteria, to the Medical Director. Notify all parties of Medical Director Determinations, and communicate alternate service options when indicated.
Responsible for the assessment of the member's and families psychosocial, medical and educational level in conjunction with hospital staff to assist in the discharge planning of hospitalized patient. This includes providing authorization for needed services through vendors in accordance with payer networks. Monitor ongoing planning process with medical team to ensure positive outcomes and timely transition to the next level of care. This concurrent evaluation will determine plan effectiveness of reaching the desired goals and outcomes. Document all pertinent information obtained through discussion with providers, patients, family members and other health care professionals in the EPIC tapestry record.
Through the discharge planning process, helps identify members who have ongoing case management needs, and refers these members to the Case Management team for outreach and follow up.
Work with the Medical Director and peers to resolve patient care problems and physician-related issues.
Coordinate and document the investigation of all potential quality of care/service issues in accordance with established policy and procedure. Report findings to the UM/QA Committee and appropriate parties.
Support all Internal Quality Assurance initiatives developed for the Utilization Management Department. Report problems and negative patterns to the Manager and work with the manager to develop corrective action plans.
Serve as one of the "On-Call Nurses" according to established policies and procedures.
Participates in the preparation of all Health Plan audits.
Run reports, as needed, to review and analyze client data (i.e. Days/K, Admits/K, ALOS).
Act as a resource for Utilization Management staff, providers, clinic staff, patients and family members. Responsible for the assessment of the individual's and family's psychosocial, medical and educational level to plan specific objectives and goals in a time specific action plan.