Utilization Review Nurse

JOB REQUIREMENTS: Demonstrates a high degree of accuracy and attention
to detail in conducting utilization review studies to evaluate the
appropriateness of admissions to the hospital, observation assignments,
lengths of stay, discharge practices, use of medical and hospital
services, and all related factors that may contribute to the effective
utilization of hospital services. -Conduct medical certification review
for medical necessity for acute care facility and services. -Use
nationally recognized, evidence-based guidelines approved by medical
staff in conjunction with medical documentation to recommend level of
care to the physician and serve as a resource to the medical staff on
issues related to admission qualifications, resource utilization,
national and local coverage determinations, and documentation
improvement opportunities. -Reviews utilization review activities for
occurrences and trends that affect the quality, cost effectiveness, and
delivery of services and assures the outcome of the review is
appropriately documented and maintained in the applicable databases and
record systems. -Submit authorizations for admission and continued stay
via email/fax and insurance portals to Medicare and Medicaid, Health
Maintenance Organizations (HMOs) and private insurers per payor
requirements. -Maintain oversight by tracking metrics and generating
reporting on usage patterns for medical necessity and appropriateness of
care against screening criteria and denials. -Collect and prepare
documentation and collaborate with physicians as needed for a
peer-to-peer review to resolve appeals and grievances. Requirements: -At
least two years of nursing experience with licensure, or eligible for
certification and/or licensure, as a Licensed Practical Nurse (LPN) in
the state. A healthcare-related associates degree or two-year program
certificate is preferred. Proficient in applying care criteria (e.g.,
InterQual Level of Care Criteria or MCG) and knowledgeable of local and
national coverage determinations and documentation thereof in Electronic
Medical Record systems based on experience or obtained within three
months of hire. -Proficient in necessary computer skills (e.g., clinical
documentation in Epic, InterQual, insurance portals, and Microsoft Excel
and Word) within three months of hire. -Recent work experience in the
hospital, hospital revenue cycle, or insurance settings preferred.
-Regularly participates in ongoing continuing education related to role.
All qualified applicants will receive consideration for employment
without regard to race, color, religion, sex, sexual orientation, gender
identity, national origin, disability, or status as a protected veteran.
APPLICATION INSTRUCTIONS: Apply Online:
www.tamarackhealth.org/current-openings/