About This Role
This nursing role involves reviewing patient admissions to ensure they are appropriate, resources are used efficiently, and third-party payer requirements are met. It suits a nurse with a background in acute hospital care and utilization management, who can analyze medical charts to confirm care aligns with established parameters.
Responsibilities
- Review patient admissions for appropriateness, efficiency of resource utilization, and compliance with third-party payer requirements
- Analyze medical charts
- Determine whether care provided is within established parameters
Requirements
- Graduation from an accredited school of nursing
- Five years of acute hospital clinical nursing experience
- One year of experience in Utilization Management, Case Management, or Clinical Documentation Improvement
- Valid license by the State of Nevada to practice as a Registered Nurse
- Minimum three years of Utilization Management experience
- Minimum of three years of experience with discharge planning in an acute care facility
- Recent documented experience with InterQual, and ability to pass the InterQual exam
- Recent documented experience with Milliman experience
- Knowledge of InterQual or Milliman utilization review criteria, Medicare/Medicaid guidelines, hospital policies and procedures, Joint Commission Accredited Health care Organizations standards, state statutes governing hospital services and health care, and other relevant regulations and standards
- Knowledge of clinical medical and nursing procedures, disease processes, department and hospital safety practices and principles, patient rights, age specific patient care practices, infection control policies and practices, department and hospital emergency response policies and procedures
- Skill in interpreting patient charts to determine whether care given is within best practice, appropriate for the diagnosis and properly documented
- Skill in collaborating, coordinating, and communicating findings
- Skill in interpreting regulations and standards for others
- Skill in writing reports, meeting minutes, and other technical documents
- Skill in analyzing statistical and other quantitative data
- Skill in applying investigative and interviewing techniques
- Skill in using a computer and a variety of software applications
- Skill in communicating with a wide variety of people and establishing interpersonal relationships to interact effectively with co-workers, supervisor, and staff in other work units and exchange or convey information
- Mobility to work in a typical office setting and use standard equipment
- Stamina to remain seated for extended periods of time
