Career Center

Education

* 2 year / Associate's Degree (Required)

* High School Diploma or GED (Required)

4 year / Bachelor's Degree (Preferred)

Certification / Licensure / Registration

*State Registered Nurse License (Required)

CCM Case Management Certification (Preferred)

Experience and Skills

*2 - 4 years Familiarity with health care reimbursement systems (Required)

*4 - 6 years Acute care hospital or similar venue. (Required)

2 - 4 years Utilization Management (Preferred)

Required Skills: Strong Verbal Communications Skills, Strong Written Communications Skills, Excellent Interpersonal Skills, Medical Terminology

Job Responsibilities and Accountabilities:

Utilization Review Nurse

COLLABORATION: Collaborates with physicians and other health care professionals to promote appropriate use of medical center resources. Provides physicians and ancillary departments with data on treatment outcomes and avoidable delays in order to promote highest quality care. Communicates and negotiates with outside agencies, including insurance carriers, in order to obtain needed services for patients and accurate reimbursement for medical center. Works with interdisciplinary team to coordinate needed services to ensure efficient continuity of care.

DOCUMENTATION AND MEASUREMENT: Uses severity of illness/ intensity of Job Description Page 2 of 3 services indexes to determine appropriateness of admissions, transfer and continued stays. Documents actions in medical record according to departmental guidelines and oversees process of exchange of information with other facilities/ agencies adhering to legal mandates regarding confidentiality. Measures effectiveness of interventions through direct communication with patients and caregivers and data collection of defined indicates (e.g. overall length of stay, readmission rates, feedback from referral services, etc.).

PATIENT CARE: Plans for care needs with active involvement of patient, significant others and hospital staff involved in treatment process. Oversees implementation of transition plans with support from internal and external agents. Monitors patients' progress and adequacy of planning process through regular communications with patients and service providers. Provides information and support to patients and families, helping them access needed resources within the medical center and community.

PROBLEM SOLVING: Identifies problems or gaps in community resources that impact outcome and takes leadership role in efforts to effect changes. Takes a leadership role in identifying opportunities to reduce risks, both financial and clinical, through analysis of resource consumption outcomes.