Utilization Review Nurse job description
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What does a Utilization Review Nurse do?
The Utilization Review Nurse plays a crucial role in ensuring patients receive appropriate care while optimizing resource utilization and cost-effectiveness. This position is vital for maintaining healthcare standards and supports the organization's operational and financial goals through meticulous case evaluation.
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What are the Key Responsibilities of Utilization Review Nurse
- Evaluate patient medical records to determine the appropriateness of care and resource utilization.
- Collaborate with healthcare providers to ensure adherence to established guidelines.
- Conduct pre-certification, concurrent, and retrospective reviews.
- Communicate with insurance companies to facilitate coverage for necessary treatments.
- Document review findings and present to relevant stakeholders.
- Identify areas for improvement in care delivery and resource utilization.
- Educate staff on best practices and protocol compliance.
What are the Skills and Requirements for a Utilization Review Nurse?
- Strong knowledge of clinical care standards and healthcare regulations.
- Excellent analytical and critical thinking skills.
- Proficient in Electronic Health Record (EHR) systems.
- Effective communication and negotiation skills.
- Attention to detail and organizational skills.
What are the KPIs to track for Utilization Review Nurse?
Performance is measured by improved care quality, optimized resource usage, and reduced admission denials through diligent case review and compliance with healthcare policies.
Care Quality
Ensuring that high-quality care guidelines are met for all patients.
Resource Optimization
Efficient use of hospital resources without compromising patient care.
Admission Denials
Reduction of insurance claim denials through effective case management.
Reports to
Director of Utilization Management
Collaborates with
Healthcare Providers, Insurance Representatives
Leads
N/A
Are any specific tools or software required for the Utilization Review Nurse role?
- EHR Systems
- Microsoft Office Suite
- Utilization Management Software
What is the qualification of Utilization Review Nurse?
Registered Nurse (RN) license with at least three years of clinical nursing experience; experience in utilization review or case management is preferred.
