Summary

　　The Utilization Review Nurse is responsible for evaluating the medical necessity and appropriateness of healthcare services and treatment as prescribed by utilization review standards. The UR Nurse works with providers, insurance companies and patients to ensure cost-effective and appropriate care. Areas of work include status management, medical necessity reviews, verification of authorization, resource utilization, and denial prevention.

　　Responsibilities

　　Completes and enters inpatient and observation admission review against standard criteria per payer guidelines

　　Prioritizes observation case review

　　Assists with level of care in collaboration with attending provider

　　Enters working diagnosis-related groups (DRGs) in the electronic medical record

　　Submits clinical information to payer per payer requirements

　　Completes continued stay reviews every 3 days or more often if required

　　Communicates with care coordinators for authorized days, level of care, medical necessity or other areas when indicated

　　Communicates with physician advisors related to status concerns or denials

　　Updates auth/cert screen in the electronic medical record

　　Works assigned queues in the electronic medical record

　　Communicates with authorization coordinator

　　Communicates in-house high dollar case information

　　Completes assigned goals

　　Requirements, Preferences and Experience

　　Experience Minimum:

　　RN with 3 years of clinical experience

　　Experience Preferred:

　　RN with 3 years of clinical experience

　　Education Minimum:

　　Diploma or Associate Degree in Nursing

　　Education Preferred:

　　BSN or MSN

　　Special Skills Minimum:

　　Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills. Problem solving; and knowledge of governmental regulations.

　　Licensure Minimum:

　　RN

　　Licensure Preferred:

　　CCM;ACM

　　About Baptist Memorial Health Care

　　At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry-healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey.

　　At Baptist, We Offer:

　　Competitive salaries

　　Paid vacation/time off

　　Continuing education opportunities

　　Generous retirement plan

　　Health insurance, including dental and vision

　　Sick leave

　　Service awards

　　Free parking

　　Short-term disability

　　Life insurance

　　Health care and dependent care spending accounts

　　Education assistance/continuing education

　　Employee referral program

　　Job Summary:

　　Position: 18447 - RN-Utilization Review

　　Facility: BMH - Desoto Hospital

　　Department: DC Case Management Admin BMH Desoto

　　Category: Nurse RN

　　Type: Clinical

　　Work Type: Full Time

　　Work Schedule: Days

　　Location: US:MS:Southaven

　　Located in the Memphis metro area REQNUMBER: 19343