Utilization Review Nurse

About This Role

The Utilization Review Nurse ensures the delivery of optimal patient care while promoting fiscal responsibility by determining medical necessity and financial liability for hospitalized patients. This role is crucial for maintaining efficient, cost-effective care management processes and ensuring compliance with regulatory requirements.

Responsibilities

• Identify clinical indications for admission
• Track hospital events and course to justify patient admission and continued stay for payer reimbursement
• Communicate with third party payers regarding patient clinical progress
• Assess and communicate potential reasons for payer denials and attempt to resolve them with the team
• Participate in activities of identifying high risk vulnerabilities to the organization
• Use critical thought processes and decision making in monitoring the continuum of care
• Support work at both UW Medical Center – Northwest and UW Medical Center - Montlake

Requirements

• 3 years of work experience in utilization management
• 5 years of nursing work experience in an acute care med-surg setting
• Bachelor's Degree in Nursing, or equivalent education and training
• Active licensure to practice as a Registered Nurse in Washington State by start date
• Knowledge of medical screening criteria
• Computer skills to appropriately navigate electronic charting and referral systems

Qualifications

• Bachelor's Degree in Nursing, or equivalent education and training
• 3 years of work experience in utilization management and 5 years of nursing work experience in an acute care med-surg setting.

Nice to Have

• Case Management certification
• Previous experience with Xsolis software
• Previous experience with MCG criteria

Skills

* Required skills

Benefits