Job Summary and ResponsibilitiesThe Utilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking.
Additionally, as a Utilization Review RN, you will collaborate with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.
This position is open to remote/out of state candidates residing in only these states:Alabama- Arizona- Arkansas- Colorado - Florida- Georgia - Idaho- Indiana - Iowa- Kansas - Kentucky- Louisiana -Missouri- Mississippi- Nebraska- New Mexico - Nevada - North Carolina - Ohio- Oklahoma- South Carolina - South Dakota- Tennessee- Texas- Utah - Virginia- West Virginia - WyomingJob RequirementsIn addition to bringing humankindness to the workplace each day, qualified candidates will need the following:
- Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
- Utilization Review experience.
- Preferred graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.
- At least five (5) years of nursing experience
- RN license in the state(s) covered is required.
Physical Requirements - Medium Work - (Exert up to 50lbs force occasionally, and/or up to 20lbs frequently, and/or up to 10lbs constantly)
Where You'll WorkWith more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.
