Utilization Review RN

Summary:

Responsible for ensuring the provision of quality patient care, effective utilization of available health services, review of the medical necessity of admissions, and the necessity for continued stay in the hospital. Analyzing patient records to ensure compliance with government and insurance company reimbursement policies; ensuring compliance with insurance, governmental and accrediting agency standards; and determining patient review dates according to established diagnostic criteria.

Qualification:

To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Job Functions:

• Obtain outpatient prior authorizations as needed
• Process appeals for denials from insurances

· Performs precertification, concurrent and retrospective reviews on all inpatient and swing bed admissions as well as any outpatient procedure that needs precertification

· Reviews patients records and evaluates patient progress and performs continuing review on medical records and identifies the need of on-going hospitalization

· Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct reviews

· Compares inpatient medical records to established criteria and confers with medical and nursing staff to determine legitimacy of treatment and length of stay

· Prepares information for notification letters for patients (guardians) providers and employers

· Responds to complaints per UR guidelines

· Maintains utilization review and appeal logs as needed

· Performs administrative duties; receives, logs in and files a variety of documents as assigned

Licensure/Certifications:

· Current Registered Nurse License (any state), Alaska Registered Nurse License required within six (6) months of hire.

· Certification in Utilization Review or Utilization Management desired.

Education & Experience:

· Current Registered Nurse License (any state), Alaska Registered Nurse License required within six (6) months of hire.

· Certification in Utilization Review or Utilization Management desired.

· Three (3) years of clinical care or nursing experience and Two (2) years’ experience Utilization Review.

· An equivalent combination of relevant education and/or training may be substituted for experience.

· Graduate of an Accredited School of Nursing; BSN preferred.

Arctic Slope Native Association, Ltd. exercises its rights in Native Hire Preference, Contracting/Subcontracting and Employment Practices applicable by law.