System Utilization Management SUM Utilization Review RN Position Available In Calhoun, Alabama

Job Description:

Summary SUMMARY:

The System Utilization Management [SUM]Utilization Review RN is responsible for ensuring the appropriateuse of healthcare resources while maintaining high- standards ofpatient care. This role involves evaluating medical necessity,assessing treatment plans, and collaborating with healthcareproviders and payers to ensure compliance with regulations andcoverage criteria. The UR RN plays a critical role in optimizingcare delivery, reducing avoidable inpatient denials, and improvingoverall healthcare.

DUTIES & ESSENTIAL JOB FUNCTIONS

NOTE:

Following are the duties performed by employees in thisclassification. However, employees may perform other related dutiesat an equivalent level. Not all duties listed are necessarilyperformed by each individual in the classification. 1. Acts as aliaison between payers, billing, and medical staff by supplyingappropriate medical information to determine level of care status.2. Collaborate with Emergency Department physicians andHospitalists to ensure accurate patient class placement (e.g.,inpatient, observation, outpatient). 3. Expeditiously refer casesto the internal/external Physician Advisor for review of requeststhat may not meet medical necessity criteria. 4. Review admissionorders and documentation to confirm alignment with regulatoryrequirements and payer guidelines. 5. Review planned admissions toensure that services are medically necessary, appropriatelyauthorized by the payer, and assigned to the correct level of care.6. Ensure compliance with federal, state, and organizationalregulations, including Medicare and Medicaid guidelines. 7. Stayinformed about CMS Conditions of Participation (COP),payer-specific requirements, and industry standards. 8. Maintainaccurate documentation of reviews, findings, and actions in the EHRsystem. 9. Conduct concurrent and admission reviews of patientrecords to assess medical necessity and adherence to evidence-basedguidelines. 10. Collaborate with care coordinators to ensure thedelivery of regulatory notices. 11. Submit clinical documentationand coordinate with insurance companies to secure properauthorizations. 12. Access payer portals to seek inpatientauthorizations. 13. Identify and address any gaps in documentationthat may affect proper classification or reimbursement. 14. Providereal-time feedback and education to clinicians regarding bestpractices in resource utilization. 15. Maintain continuedprofessional growth and education to meet continuing educationrequirements. 16. Participate in orientation of fresh staff asrequested by the Manager of Utilization Management. 17. Maintainsknowledge of current trends and changes in healthcare delivery asit pertains to utilization review (e.g., medical necessity, levelof care) by participating in appropriate educational opportunities.(Webinars, conferences, local training, Compass Modules).

MINIMUMQUALIFICATIONS

Required Education:

BSN from an accredited schoolof nursing

Preferred Education:

Master’s degree in nursing

RequiredExperience:

Minimum three (3) years of experience in UtilizationManagement or Case Management AND proficiency in applying InterQualCriteria (95% or higher IRR)

Required Licenses/Certifications:

Valid license to practice as a Registered Nurse in the

State ofCalifornia Preferred Licenses/Certifications:

Certified CaseManager (CCM) or Accredited Case Manager (ACM) Highland GeneralHospital SYS Utilization Management Services As Needed /

Per DiemVaries Nursing FTE:

0.01